Assessing efficacy of a web-based smoking cessation tool - QuitAdvisorMD: Protocol for a practice-based, clustered, randomized control trial.

Background: Smoking remains the leading cause of preventable death, yet physicians inconsistently provide best-practices cessation advice to smokers. Point-of-care digital health tools can prompt and assist physicians to provide improved smoking cessation counseling. QuitAdvisorMD is a comprehensive web-based counseling and management digital health tool designed to guide smoking cessation counseling at the point-of-care. The tool enables clinicians to assess patient readiness to change and then deliver stage-appropriate interventions, while also incorporating Motivational Interviewing techniques. We present the research protocol to assess the efficacy of QuitAdvisorMD to change frequency and quality of smoking cessation counseling and its effect on patient quit rates. Methods: A practice-based, clustered, randomized controlled trial will be used to evaluate QuitAdvisorMD. Cluster design will be used where patients are clustered within primary care practices and practices will be randomized to either the intervention (QuitAdvisorMD) or control group. The primary outcome is frequency and quality of clinician initiated smoking cessation counseling. Secondary outcomes include, 1) changes in physician knowledge, skills and perceived self-efficacy in providing appropriate stage-based smoking cessation counseling and 2) patient quit attempts. Analyses will be conducted to determine pre- and post-test individual clinician outcomes and between intervention and control group practices for patient outcomes. Conclusion: Results from this study will provide important insights regarding the ability of an integrated, web-based counseling and management tool (QuitAdvisorMD) to impact both the quality and efficacy of smoking cessation counseling in primary care settings.

Role of Age and Competing Risk of Death in the Racial Disparity of Kidney Failure Incidence after Onset of CKD.

SIGNIFICANCE STATEMENT: Black adults in the United States have 2-4 times higher incidence of kidney failure than White adults. Yet, the reasons underlying this disparity remain poorly understood. Among 547,188 US veterans with new-onset CKD, according to a new race-free GFR equation, Black veterans had a 2.5-fold higher cumulative incidence of kidney failure, compared with White veterans, in any follow-up period from CKD onset. This disparity resulted from a combination of higher hazards of progression to kidney failure and lower hazards of competing-risk death in Black veterans. Both, in turn, were largely explained by the younger age at CKD onset in Black veterans, underscoring an urgent need to prevent early onset and slow progression of CKD in younger Black adults. BACKGROUND: The Black adult population is well known to have higher incidence of kidney failure than their White counterpart in the United States, but the reasons underlying this disparity are unclear. We assessed the racial differences in kidney failure and death from onset of CKD on the basis of the race-free 2021 CKD Epidemiology Collaboration equation and examined the extent to which these differences could be explained by factors at the time of CKD onset. METHODS: We analyzed a national cohort consisting of 547,188 US veterans (103,821 non-Hispanic Black and 443,367 non-Hispanic White), aged 18-85 years, with new-onset CKD between 2005 and 2016 who were followed through 10 years or May 2018 for incident kidney failure with replacement therapy (KFRT) and pre-KFRT death. RESULTS: At CKD onset, Black veterans were, on average, 7.8 years younger than White veterans. In any time period from CKD onset, the cumulative incidence of KFRT was 2.5-fold higher for Black versus White veterans. Meanwhile, Black veterans had persistently >2-fold higher hazards of KFRT throughout follow-up (overall hazard ratio [95% confidence interval], 2.38 [2.31 to 2.45]) and conversely had 17%-48% decreased hazards of pre-KFRT death. These differences were reduced after accounting for the racial difference in age at CKD onset. CONCLUSIONS: The 2.5-fold higher cumulative incidence of kidney failure in Black adults resulted from a combination of higher hazards of progression to kidney failure and lower hazards of the competing risk of death, both of which can be largely explained by the younger age at CKD onset in Black compared with White adults.

Role of Anemia in Dementia Risk Among Veterans With Incident CKD.

RATIONALE & OBJECTIVE: Although some evidence exists of increased dementia risk from anemia, it is unclear whether this association persists among adults with CKD. Anemia may be a key marker for dementia among adults with CKD, so we evaluated whether anemia is associated with an increased risk of dementia among adults with CKD. STUDY DESIGN: Retrospective cohort study. SETTING & PARTICIPANTS: The study included 620,095 veterans aged≥45 years with incident stage 3 CKD (estimated glomerular filtration rate [eGFR]<60mL/min/1.73m2) between January 2005 and December 2016 in the US Veterans Health Administration system and followed through December 31, 2018, for incident dementia, kidney failure, or death. EXPOSURE: Anemia was assessed based on the average of hemoglobin levels (g/L) during the 2 years before the date of incident CKD and categorized as normal, mild, or moderate/severe anemia (≥12.0, 11.0-11.9,<11.0g/dL, respectively, for women, and≥13.0, 11.0-12.9,<11.0g/dL for men). OUTCOME: Dementia and the composite outcome of kidney failure or death. ANALYTICAL APPROACH: Adjusted cause-specific hazard ratios were estimated for each outcome. RESULTS: At the time of incident CKD, the mean age of the participants was 72 years, 97% were male, and their mean eGFR was 51mL/min per 1.73m2. Over a median 4.1 years of follow-up, 92,306 veterans (15%) developed dementia before kidney failure or death. Compared with the veterans with CKD without anemia, the multivariable-adjusted models showed a 16% (95% CI, 14%-17%) significantly higher risk of dementia for those with mild anemia and a 27% (95% CI, 23%-31%) higher risk with moderate/severe anemia. Combined risk of kidney failure or death was higher at 39% (95% CI, 37%-40%) and 115% (95% CI, 112%-119%) for mild and moderate/severe anemia, respectively, compared with no anemia. LIMITATIONS: Residual confounding from the observational study design. Findings may not be generalizable to the broader US population. CONCLUSIONS: Anemia was significantly associated with an increased risk of dementia among veterans with incident CKD, underscoring the role of anemia as a predictor of dementia risk. PLAIN-LANGUAGE SUMMARY: Adults with chronic kidney disease (CKD) often have anemia. Prior studies among adults in the general population suggest anemia is a risk factor for dementia, though it is unclear whether this association persists among adults with CKD. In this large study of veterans in the United States, we studied the association between anemia and the risk of 2 important outcomes in this population: (1) dementia and (2) kidney failure or death. We found that anemia was associated with a greater risk of dementia as well as risk of kidney failure or death. The study findings therefore emphasize the role of anemia as a key predictor of dementia risk among adults with CKD.

Overcoming barriers to implementing new guideline-directed therapies for chronic kidney disease.

For the first time in many years, guideline-directed drug therapies have emerged that offer substantial cardiorenal benefits, improved quality of life and longevity in patients with chronic kidney disease (CKD) and type 2 diabetes. These treatment options include sodium-glucose cotransporter-2 inhibitors, nonsteroidal mineralocorticoid receptor antagonists and glucagon-like peptide-1 receptor agonists. However, despite compelling evidence from multiple clinical trials, their uptake has been slow in routine clinical practice, reminiscent of the historical evolution of angiotensin-converting enzyme inhibitor and angiotensin II receptor blocker use. The delay in implementation of these evidence-based therapies highlights the many challenges to optimal CKD care, including: (i) clinical inertia; (ii) low CKD awareness; (iii) suboptimal kidney disease education among patients and providers; (iv) lack of patient and community engagement; (v) multimorbidity and polypharmacy; (vi) challenges in the primary care setting; (vii) fragmented CKD care; (viii) disparities in underserved populations; (ix) lack of public policy focused on health equity; and (x) high drug prices. These barriers to optimal cardiorenal outcomes can be ameliorated by a multifaceted approach, using the Chronic Care Model framework, to include patient and provider education, patient self-management programs, shared decision making, electronic clinical decision support tools, quality improvement initiatives, clear practice guidelines, multidisciplinary and collaborative care, provider accountability, and robust health information technology. It is incumbent on the global kidney community to take on a multidimensional perspective of CKD care by addressing patient-, community-, provider-, healthcare system- and policy-level barriers.

Associations of Race, Ethnicity, and Social Determinants of Health With Colorectal Cancer Screening.

BACKGROUND: Racial and ethnic disparities in receipt of recommended colorectal cancer screening exist; however, the impact of social determinants of health on such disparities has not been recently studied in a national cohort. OBJECTIVE: This study aimed to determine whether social determinants of health attenuate racial disparities in receipt of colorectal cancer screening. DESIGN: This was a cross-sectional telephone survey of self-reported race and ethnicity and up-to-date colorectal cancer screening. Associations between race/ethnicity and colorectal cancer screening were tested before and after adjustment for demographics, behavioral factors, and social determinants of health. SETTING: This was a nationally representative telephone survey of US residents in 2018. PATIENTS: The patients included were US residents aged 50 to 75 years. MAIN OUTCOME MEASURES: The primary outcome was up-to-date colorectal cancer screening status, according to 2008 US Preventive Services Task Force recommendations. RESULTS: This study included 226,106 respondents aged 50 to 75 years. Before adjustment, all minority racial and ethnic groups demonstrated a significantly lower odds of screening than those of non-Hispanic white respondents. After adjustment for demographics, behavioral factors, and social determinants of health, compared to non-Hispanic white respondents, odds of screening were found to be increased among non-Hispanic black respondents (OR, 1.10; p = 0.02); lower but attenuated among Hispanic respondents (OR, 0.73; p < 0.001), non-Hispanic American Indian/Alaskan Native respondents (OR, 0.85; p = 0.048), and non-Hispanic respondents of other races (OR, 0.82; p = 0.01); and lower but not attenuated among non-Hispanic Asian respondents (OR, 0.68; p < 0.001). LIMITATIONS: Recall bias, participant bias, and residual confounding. CONCLUSIONS: Adjustment for social determinants of health reduced racial and ethnic disparities in colorectal cancer screening among all minority racial and ethnic groups except non-Hispanic Asian individuals; however, other unmeasured confounders likely exist. See Video Abstract at http://links.lww.com/DCR/B977 . ASOCIACIN DE RAZA, ETNICIDAD Y DETERMINANTES SOCIALES DE LA SALUD CON LA DETECCIN DEL CNCER COLORRECTAL: ANTECEDENTES: Existen disparidades raciales y étnicas en la recepción de las pruebas recomendadas de detección de cáncer colorrectal; sin embargo, el impacto de los determinantes sociales de la salud en dichas disparidades no se ha estudiado recientemente en una cohorte nacional.OBJETIVO: El objetivo de este estudio fue determinar si los determinantes sociales de la salud atenúan las disparidades raciales en la recepción de pruebas de detección del cáncer colorrectal.DISEÑO: Encuesta telefónica transversal de raza y etnia autoinformada y detección actualizada de cáncer colorrectal. Las asociaciones entre la raza/etnicidad y la detección del cáncer colorrectal se probaron antes y después del ajuste por demografía, factores conductuales y determinantes sociales de la salud.ESCENARIO: Esta fue una encuesta telefónica representativa a nivel nacional de los residentes de EE. UU. en 2018.PACIENTES: Los pacientes eran residentes de EE. UU. de 50 a 75 años.PRINCIPALES MEDIDAS DE RESULTADO: Estado actualizado de detección de cáncer colorrectal, según las recomendaciones del Grupo de Trabajo de Servicios Preventivos de EE. UU. de 2008.RESULTADOS: Este estudio incluyó a 226.106 encuestados de 50 a 75 años. Antes del ajuste, todos los grupos étnicos y raciales minoritarios demostraron probabilidades significativamente más bajas de detección en comparación con los encuestados blancos no hispanos. Después del ajuste por demografía, factores conductuales y determinantes sociales de la salud, en comparación con los encuestados blancos no hispanos, las probabilidades de detección aumentaron entre los encuestados negros no hispanos (OR 1,10, p = 0,02); más bajo pero atenuado entre los encuestados hispanos (OR 0,73, p < 0,001), los encuestados indios americanos/nativos de Alaska no hispanos (OR 0,85, p = 0,048) y los encuestados no hispanos de otras razas (OR 0,82, p = 0,01); y menor pero no atenuado entre los encuestados asiáticos no hispanos (OR 0,68, p < 0,001).LIMITACIONES: Sesgo de recuerdo y sesgo de participante, así como confusión residual.CONCLUSIONES: El ajuste para los determinantes sociales de la salud redujo las disparidades raciales y étnicas en la detección del cáncer colorrectal entre todos los grupos étnicos y raciales minoritarios, excepto las personas asiáticas no hispanas; sin embargo, es probable que existan otros factores de confusión no medidos. Consulte Video Resumen en http://links.lww.com/DCR/B977 . (Traducción-Dr. Felipe Bellolio ).

An Examination of Psychological Stress, Fatigue, Sleep, and Physical Activity in Chinese Americans.

Chinese Americans comprise the largest Asian subgroup in the U.S. Yet, little research has focused on the well-being of this population. This study aimed to (1) examine psycho-physiological health (psychological stress and fatigue) and lifestyle behaviors (sleep and physical activity) between Chinese Americans and whites, and (2) investigate whether race and lifestyle behaviors were independent predictors of psycho-physiological health. This study included 87 middle-aged healthy adults (41 Chinese Americans, 46 whites). Each participant underwent a two-night actigraphy-based sleep assessment. Chinese Americans reported higher psychological stress and fatigue, had poorer objective sleep outcomes (shorter sleep duration, lower sleep efficiency, and longer sleep onset), and engaged in lower physical activity levels than whites. Race and poor perceived sleep quality were independently associated with high psychological stress and fatigue. The findings warrant further exploration of social and cultural determinants of health in this minority group to reduce health disparities.

Age-Related Association between Multimorbidity and Mortality in US Veterans with Incident Chronic Kidney Disease.

INTRODUCTION: Mortality is an important long-term indicator of the public health impact of chronic kidney disease (CKD). We investigated the role of individual comorbidities and multimorbidity on age-specific mortality risk among US veterans with new-onset CKD. METHODS: The cohort included 892,005 veterans aged ≥18 years with incident CKD stage 3 between January 2004 and April 2018 in the US Veterans Health Administration (VHA) system and followed until death, December 2018, or up to 10 years. Incident CKD was defined as the first-time estimated glomerular filtration rate (eGFR) was <60 mL/min/1.73 m2 for >3 months. Comorbidities were ascertained using inpatient and outpatient clinical records in the VHA system and Medicare claims. We estimated death rates for any cardiovascular disease (CVD, a composite of 6 CVD conditions) and 15 non-CVD comorbidities, and adjusted risks of death (hazard ratio [HR], 95% confidence interval [CI]) overall and by age group at CKD incidence. RESULTS: At CKD incidence, the mean age was 72 years, and 97% were male; the mean eGFR was 52 mL/min/1.73 m2, and 95% had ≥2 comorbidities (median, 4) in addition to CKD. During a median follow-up of 4.5 years, among the 16 comorbidities, CVD was associated with the highest relative risk of death in younger veterans (HR 1.96 [95% CI: 1.61-2.37] in ages 18-44 years and HR 1.66 [1.63-1.70] in ages 45-64 years). Dementia was associated with the highest relative risk of death among older veterans (HR 1.71 [1.68-1.74] in ages 65-84 years and HR 1.69 [1.65-1.73] in ages 85-100 years). The additive effect of multimorbidity on risk of death was stronger in younger than older veterans. Compared to having 1 or no comorbidity at CKD onset, the risk of death with ≥5 comorbidities was >7-fold higher among veterans aged 18-44 years and >2-fold higher among veterans aged 85-100 years. CONCLUSION: The large burden of comorbidities in US veterans with newly identified CKD places them at the risk of premature death. Compared with older veterans, younger veterans with multiple comorbidities, particularly with CVD, at CKD onset are at an even higher relative risk of death.

Exploration and Comparison of Contextual Characteristics and Mistreatment Prevalence Among Older American Indian and Alaska Native Respondents: Secondary Analysis of the National Elder Mistreatment Study.

Limited research on elder abuse among American Indians and Alaska Natives (AIANs) suggests a higher prevalence of abuse. Using data from the National Elder Mistreatment Study (NEMS), we compared contextual characteristics and elder mistreatment prevalence rates from a community-based sample of AIAN (n = 195) and Black (n = 437) and White (n = 5,013) respondents. There were differences in the prevalence of 16 abuse types and the 23 contextual variables. AIAN respondents had more similarities compared with Black respondents than White respondents, though differences existed. The cumulative prevalence of emotional, physical, and sexual mistreatment in the past year, neglect, and financial abuse by a family member for the AIAN group was 33%, almost double the 17.1% reported in the NEMS study. Over their lifetime, 29.7% of AIAN respondents reported experiencing two or more types of neglect, exploitation, or mistreatment. Almost one fourth of AIAN respondents reported emotional abuse since 60 years of age (the most commonly occurring abuse type)-nearly double that of White respondents. This is the first study to offer comparative prevalence of elder abuse for both AIAN older males and females that draws from a nationally representative sample. The study also provides descriptive analysis of important contextual information within the AIAN population, an underrepresented racial group in elder abuse research. Disaggregating nonmajority racial groups to examine contextual variables and the prevalence of elder mistreatment in the NEMS data set specific to AIAN respondents fills a knowledge gap. Known prevalence of various abuse typologies among AIAN elders can be useful in setting priorities for community planning and response, and in prioritization of funding for future research on causative mechanisms by abuse type, screening, and interventions at various levels. Findings may facilitate development of culturally specific evidence-based prevention and intervention practices aimed at needs specific to AIAN older adults.

The Effects of the Medical Pause on Physiological Stress Markers among Health Care Providers: A Pilot Randomized Controlled Trial.

Contemplative practices promote well-being, work engagement and resilience among health care providers. We examined the impact of The Pause, a brief contemplative intervention, on health care providers' physiological stress response. Participants were randomly assigned to either The Pause or the control group. They participated in a high-fidelity, stressful medical simulation. Following the simulation, intervention group practiced The Pause. Outcome measures were heart rate variability, heart rate, and blood pressure. We adjusted for baseline physiological variables, sociodemographic variables, self-care practices, and perceived stress. Participants in the intervention group had a standard deviation of the normal-to-normal RR intervals (heart rate variability indicator) that was 13.8 (95% CI 4.0, 23.5; p < .01) points higher than those in the control group. There were no significant effects of The Pause on heart rate or blood pressure. The Pause may reduce stress reactivity, increase heart rate variability, and enhance resilience in health care providers.

Association of a Substance Use Disorder with Infectious Diseases among Adult Home Healthcare Patients with a Venous Access Device.

Substance use disorders (SUDs) and high incidence of infectious diseases are both critical public health issues. Among patients who use a venous access device (VAD) in home care settings, SUDs may play a role in increasing their risk of having a concurrent infectious disease. This study examined the association of SUD with infectious diseases among adult home healthcare patients with a VAD. We identified adult patients with an existing VAD who were admitted to a home healthcare agency August 1, 2017-July 31, 2018 from the electronic health records of a large Medicare-certified agency. Four serious infectious diseases (endocarditis, epidural abscess, septic arthritis, and osteomyelitis) and SUD related to injectable drugs were identified using relevant ICD-10 codes. Multiple logistic regression was performed to examine the association. Of 416 patients with a VAD, 12% (n = 50) had at least one diagnosis of a serious infectious disease. The percentage of patients who had a serious infectious disease was 40% among those with SUDs, compared with only 11% among those without SUDs. After adjusting for age and sex, the odds of having a serious infectious disease was 3.52 times greater for those with SUDs compared with those without (odds ratio [95% confidence interval], 4.52 [1.48-13.79], n = .008). Our findings suggest that home healthcare patients with a VAD and a documented SUD diagnosis may have an increased risk of having a concurrent serious infectious disease. Therefore, patients with an SUD and a VAD would need more attention from home healthcare providers to prevent a serious infectious disease. Further research is suggested on modalities of care for individuals with an SUD and VAD to reduce the incidence of infectious diseases so that care can be delivered safely and efficiently in a home healthcare setting.

Sleep moderates the association between arterial stiffness and 24-hour blood pressure variability.

BACKGROUND: Arterial stiffness and increased blood pressure variability (BPV) are important subclinical cardiovascular diseases (CVDs). Evidence is accumulating that poor sleep is associated with subclinical CVDs. The purpose of our study was to investigate how sleep was related to arterial stiffness and BPV. We also explored whether sleep moderated the association between arterial stiffness and BPV. METHODS: We conducted a cross-sectional study including 78 healthy adults aged between 35 and 64 years. Variables of interest were: 1) objective seep characteristics, assessed with a wrist actigraphy for two consecutive nights; 2) arterial stiffness, measured by carotid-femoral pulse wave velocity (cfPWV); and 3) BPV, measured using an ambulatory blood pressure monitor over 24 h and estimated by average real variability. RESULTS: Lower sleep efficiency was an independent predictor of higher cfPWV and higher systolic BPV, while longer wake after sleep onset (WASO) was an independent predictor of higher cfPWV only. In addition, cfPWV showed a positive relationship with systolic BPV, and this relationship was moderated by sleep efficiency and WASO, respectively. The relationship between cfPWV and systolic BPV became stronger among individuals who had a level of sleep efficiency lower than 84% and who had WASO higher than 67 min, respectively. CONCLUSION: Our study showed that poor sleep not only directly linked with arterial stiffness and BPV but also moderated the relationship between these two subclinical CVDs. These findings suggest that improving sleep quality could be a target intervention to promote cardiovascular health in clinical practice.

Moral distress among nurses: A mixed-methods study.

BACKGROUND: Moral distress is recognized as a problem affecting healthcare professionals globally. Unaddressed moral distress may lead to withdrawal from the moral dimensions of patient care, burnout, or leaving the profession. Despite the importance, studies related to moral distress are scant in Thailand. OBJECTIVE: This study aims to describe the experience of moral distress and related factors among Thai nurses. DESIGN: A convergent parallel mixed-methods design was used. The quantitative and qualitative data were collected in parallel using the Measure of Moral Distress for Healthcare Professionals and interview guide. The analysis was conducted separately and then integrated. PARTICIPANTS: Participants were Thai nurses from two large tertiary care institutions in a Southern province of Thailand. ETHICAL CONSIDERATIONS: This study was approved by our organization's Institutional Review Board for Health Sciences Research, and by the Institutional Review Boards of the two local institutions in Thailand. Permission from the publisher was received to translate and utilize the Measure of Moral Distress (MMD-HP) under the license number: 4676990097151. RESULTS: A total of 462 participants completed the survey questions. The top 7 causes of moral distress were related to system-level root causes and end-of-life care situations. Hierarchical multiple regression showed that work units, considering leaving position, and number of moral distress episodes in the past year were significant predictors of moral distress. Twenty interviews demonstrated three main themes of distressing causes: (1) powerlessness (at patients/family-, team-, and organizational-levels), (2) end-of-life issues, and (3) poor team function (poor communication and collaboration, incompetent healthcare providers, and inappropriate behavior of colleagues). The integration of data from both components indicated that the qualitative interviews enrich the quantitative findings, especially as related to the top 7 causes of moral distress. DISCUSSION: Although the experience of moral distress among Thai nurses is similar to studies conducted elsewhere, the patient's and family's religious perspective that ties into the concept of moral distress needs to be explored. CONCLUSIONS: Although the root causes of moral distress are similar among different cultures, the experience of Thai nurses may vary according to culture and context.

Global Epidemiology of End-Stage Kidney Disease and Disparities in Kidney Replacement Therapy.

BACKGROUND: The global epidemiology of end-stage kidney disease (ESKD) reflects each nation's unique genetic, environmental, lifestyle, and sociodemographic characteristics. The response to ESKD, particularly regarding kidney replacement therapy (KRT), depends on local disease burden, culture, and socioeconomics. Here, we explore geographic variation and global trends in ESKD incidence and prevalence and examine variations in KRT modality, practice patterns, and mortality. We conclude with a discussion on disparities in access to KRT and strategies to reduce ESKD global burden and to improve access to treatment in low- and middle-income countries (LMICs). SUMMARY: From 2003 to 2016, incidence rates of treated ESKD were relatively stable in many higher income countries but rose substantially predominantly in East and Southeast Asia. The prevalence of treated ESKD has increased worldwide, likely due to improving ESKD survival, population demographic shifts, higher prevalence of ESKD risk factors, and increasing KRT access in countries with growing economies. Unadjusted 5-year survival of ESKD patients on KRT was 41% in the USA, 48% in Europe, and 60% in Japan. Dialysis is the predominant KRT in most countries, with hemodialysis being the most common modality. Variations in dialysis practice patterns account for some of the differences in survival outcomes globally. Worldwide, there is a greater prevalence of KRT at higher income levels, and the number of people who die prematurely because of lack of KRT access is estimated at up to 3 times higher than the number who receive treatment. Key Messages: Many people worldwide in need of KRT as a life-sustaining treatment do not receive it, mostly in LMICs where health care resources are severely limited. This large treatment gap demands a focus on population-based prevention strategies and development of affordable and cost-effective KRT. Achieving global equity in KRT access will require concerted efforts in advocating effective public policy, health care delivery, workforce capacity, education, research, and support from the government, private sector, nongovernmental, and professional organizations.

Mapping epileptic directional brain networks using intracranial EEG data.

The human brain is a directional network system, in which brain regions are network nodes and the influence exerted by one region on another is a network edge. We refer to this directional information flow from one region to another as directional connectivity. Seizures arise from an epileptic directional network; abnormal neuronal activities start from a seizure onset zone and propagate via a network to otherwise healthy brain regions. As such, effective epilepsy diagnosis and treatment require accurate identification of directional connections among regions, i.e., mapping of epileptic patients' brain networks. This article aims to understand the epileptic brain network using intracranial electroencephalographic data-recordings of epileptic patients' brain activities in many regions. The most popular models for directional connectivity use ordinary differential equations (ODE). However, ODE models are sensitive to data noise and computationally costly. To address these issues, we propose a high-dimensional state-space multivariate autoregression (SSMAR) model for the brain's directional connectivity. Different from standard multivariate autoregression and SSMAR models, the proposed SSMAR features a cluster structure, where the brain network consists of several clusters of densely connected brain regions. We develop an expectation-maximization algorithm to estimate the proposed model and use it to map the interregional networks of epileptic patients in different seizure stages. Our method reveals the evolution of brain networks during seizure development.

Effect of preventive care interventions on pressure ulcer rates in a national sample of rural and urban nursing units: Longitudinal associations over 4 years.

BACKGROUND: Pressure ulcer rates are persistently high despite years of research and practice policies focused on prevention. Prior research found crosssectional associations between care interventions, hospital and nursing unit characteristics and pressure ulcer rates. Whether these associations persist over time is unknown. Finally, comparisons of quality measures across rural and urban location have mixed findings. OBJECTIVE: Our study examined effects of care interventions on unit-acquired pressure ulcer rates over 4 years controlling for community, hospital, and nursing unit characteristics in rural and urban locations. DESIGN: Guided by contingency theory a longitudinal study was conducted to examine associations between context, staffing, care interventions, nurse outcomes, and pressure ulcer rates, using unit-level data from the National Database of Nursing Quality IndicatorsⓇ 2010-2013 (16 quarters) augmented with data on rural classifications and case mix index. Ulcer rates were measured as percentage of patients with a nursing unit-acquired pressure ulcer. The three care interventions were unit-percentage of patients receiving skin assessment on admission, receiving risk assessment on admission, and receiving any risk assessment before the pressure ulcer. Nursing unit characteristics were RN staffing, education, and experience. Nurse outcomes were job satisfaction and intent-to-stay. PARTICIPANTS: We included 5761 units (332 rural and 5429 urban) in 772 hospitals (89 rural and 683 urban) that reported ulcer rates in two or more quarters during the study period. METHODS: Rural and urban units were examined separately using multilevel binomial regression in which within-unit changes in pressure ulcer rates were related to the within-unit changes in the explanatory variables, controlling for region, hospital size, unit type, case mix index, and percentage of patients at risk for pressure ulcers. RESULTS: An increase in the three care interventions, RN skill mix, and the two nurse outcomes were associated with a decrease in unit-acquired pressure ulcers. For example, in rural units a 10% increase in unit-percentage of any risk assessment and in urban units a 10% increase in skin assessment on admission were associated with a 21% and 5% decrease in the odds of developing an ulcer. A 10% increase in RN skill mix was associated with 17-18% and 5-6% decrease in ulcer rates in rural and urban units respectively. CONCLUSION: Hospitals aiming to improve pressure ulcer prevention should focus on organizational structures that support improved nurses work environments and workflow that will enhance nursing care interventions. Future studies should include both contextual and patient characteristics along with care interventions.

Racial and Ethnic Variations in Mortality Rates for Patients Undergoing Maintenance Dialysis Treated in US Territories Compared with the US 50 States.

BACKGROUND AND OBJECTIVES: In the United States mortality rates for patients treated with dialysis differ by racial and/or ethnic (racial/ethnic) group. Mortality outcomes for patients undergoing maintenance dialysis in the United States territories may differ from patients in the United States 50 states. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS: This retrospective cohort study of using US Renal Data System data included 1,547,438 adults with no prior transplantation and first dialysis treatment between April 1, 1995 and September 28, 2012. Cox proportional hazards regression was used to calculate hazard ratios (HRs) of death for the territories versus 50 states for each racial/ethnic group using the whole cohort and covariate-matched samples. Covariates included demographics, year of dialysis initiation, cause of kidney failure, comorbid conditions, dialysis modality, and many others. RESULTS: Of 22,828 patients treated in the territories (American Samoa, Guam, Puerto Rico, Virgin Islands), 321 were white, 666 were black, 20,299 were Hispanic, and 1542 were Asian. Of 1,524,610 patients in the 50 states, 838,736 were white, 444,066 were black, 182,994 were Hispanic, and 58,814 were Asian. The crude mortality rate (deaths per 100 patient-years) was lower for whites in the territories than the 50 states (14 and 29, respectively), similar for blacks (18 and 17, respectively), higher for Hispanics (27 and 16, respectively), and higher for Asians (22 and 15). In matched analyses, greater risks of death remained for Hispanics (HR, 1.65; 95% confidence interval, 1.60 to 1.70; P<0.001) and Asians (HR, 2.01; 95% confidence interval, 1.78 to 2.27; P<0.001) living in the territories versus their matched 50 states counterparts. There were no significant differences in mortality among white or black patients in the territories versus the 50 states. CONCLUSIONS: Mortality rates for patients undergoing dialysis in the United States territories differ substantially by race/ethnicity compared with the 50 states. After matched analyses for comparable age and risk factors, mortality risk no longer differed for whites or blacks, but remained much greater for territory-dwelling Hispanics and Asians.

Association of Race/Ethnicity, Stage, and Survival in Oral Cavity Squamous Cell Carcinoma: A SEER Study.

OBJECTIVE: Survival differences in oral cancer between black and white patients have been reported, but the contributing factors, especially the role of stage, are incompletely understood. Furthermore, the outcomes for Hispanic and Asian patients have been scarcely examined. STUDY DESIGN: Retrospective, population-based national study. SETTING: Surveillance, Epidemiology, and End Results 18 Custom database (January 1, 2010, to December 31, 2014). SUBJECTS AND METHODS: In total, 7630 patients with primary squamous cell carcinoma in the oral cavity were classified as non-Hispanic white (white), non-Hispanic black (black), Hispanic, or Asian. Cox regression was used to obtain unadjusted and adjusted hazard ratios (HRs) of 5-year mortality for race/ethnicity with sequential adjustments for stage and other covariates. Logistic regression was used to examine the relationship between race/ethnicity and stage with adjusted odds ratios (aORs). RESULTS: The cohort consisted of 75.0% whites, 7.6% blacks, 9.1% Hispanics, and 8.3% Asians. Compared to whites, the unadjusted HR for all-cause mortality for blacks was 1.68 (P < .001), which attenuated to 1.15 (P = .039) after adjusting for stage and became insignificant after including insurance. The unadjusted HRs for all-cause mortality were not significant for Hispanics and Asians vs whites. Compared to whites, blacks and Hispanics were more likely to present at later stages (aORs of 2.63 and 1.42, P < .001, respectively). CONCLUSION: The greater mortality for blacks vs whites was largely attributable to the higher prevalence of later stages at presentation and being uninsured among blacks. There was no statistically significant difference in mortality for Hispanics vs whites or Asians vs whites.

Use of Percutaneous Coronary Intervention Among Black and White Patients With End-Stage Renal Disease in the United States.

Background Racial disparities in invasive cardiac procedures such as percutaneous coronary intervention (PCI) in the general population are well documented; however, national-level data on such disparities in the end-stage renal disease (ESRD) population are lacking. We assessed racial differences in PCI between black and white patients with ESRD on maintenance dialysis. Methods and Results Using the US Renal Data System database, we abstracted Medicare inpatient procedure claims for PCI in a cohort of 268 575 Medicare-primary patients who initiated treatment on maintenance dialysis from January 1, 2009, through June 1, 2013. We conducted Cox regression analyses with PCI being the event, adjusted for demographic characteristics, Hispanic ethnicity, cause of ESRD, comorbidities, and socioeconomic factors. We also assessed the probability of PCI, accounting for death or transplant in competing risk regression models. The crude incidence rate of PCI among white patients was 25.8 per 1000 patient-years versus 15.5 per 1000 patient-years among black patients. Cox regression analyses demonstrated that black patients were significantly less likely to undergo PCI compared with white patients (adjusted hazard ratio: 0.64; 95% CI, 0.62-0.67; P<0.001). In the competing risk models, the racial gap for PCI among black and white patients remained significant with death (subdistribution hazard ratio: 0.81; 95% CI, 0.76-0.85; P<0.001) or transplant as a competing event (subdistribution hazard ratio: 0.67; 95% CI, 0.64-0.70; P<0.001). Conclusions A racial gap exists in PCI use among dialysis patients despite having comprehensive coverage with Medicare. These findings persisted despite accounting for demographic, clinical, socioeconomic factors, and death or transplant as competing events.

Direct and indirect costs associated with stereotactic radiosurgery or open surgery for medial temporal lobe epilepsy: Results from the ROSE trial.

OBJECTIVE: To determine whether a less-invasive approach to surgery for medically refractory temporal lobe epilepsy is associated with lower health care costs and costs of lost productivity over time, compared to open surgery. METHODS: We compared direct medical costs and indirect productivity costs associated with treatment with stereotactic radiosurgery (SRS) or anterior temporal lobectomy (ATL) in the ROSE (Radiosurgery or Open Surgery for Epilepsy) trial. Health care use was abstracted from hospital bills, the study database, and diaries in which participants recorded health care use and time lost from work while seeking care. Costs of use were calculated using a Medicare costing approach used in a prior study of the costs of ATL. The power of many analyses was limited by the sample size and data skewing. RESULTS: Combined treatment and follow-up costs (in thousands of US dollars) did not differ between SRS (n = 20, mean = $76.6, 95% confidence interval [CI] = 50.7-115.6) and ATL (n = 18, mean = $79.0, 95% CI = 60.09-103.8). Indirect costs also did not differ. More ATL than SRS participants were free of consciousness-impairing seizures in each year of follow-up (all P < 0.05). Costs declined following ATL (P = 0.005). Costs tended to increase over the first 18 months following SRS (P = 0.17) and declined thereafter (P = 0.06). This mostly reflected hospitalizations for SRS-related adverse events in the second year of follow-up. SIGNIFICANCE: Lower initial costs of SRS for medial temporal lobe epilepsy were largely offset by hospitalization costs related to adverse events later in the course of follow-up. Future studies of less-invasive alternatives to ATL will need to assess adverse events and major costs systematically and prospectively to understand the economic implications of adopting these technologies.