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We develop a model of rational self-medication in which individuals use potentially dangerous or addictive substances (e.g., alcohol) to manage symptoms of illness (e.g., depression) outside of formal medical care. A model implication is that the emergence of better treatments reduces incentives to self-medicate. To investigate, we use forty years of longitudinal data from the Framingham Heart Study and leverage the exogenous introduction of selective serotonin reuptake inhibitors (SSRIs). We demonstrate an economically meaningful reduction in alcohol consumption when SSRIs became available. Our findings illustrate how the effects of medical innovation operate, in part, through changes in behavior.
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Inibidores Seletivos de Recaptação de Serotonina , Automedicação , Humanos , Inibidores Seletivos de Recaptação de Serotonina/uso terapêutico , Consumo de Bebidas Alcoólicas , Masculino , Feminino , Estudos Longitudinais , Depressão/tratamento farmacológico , Pessoa de Meia-Idade , MotivaçãoRESUMO
OBJECTIVE: To describe common methodological problems that arise in comparisons of Medicare Advantage (MA) and Traditional Medicare (TM) and within-MA studies and provide suggestions of how researchers can address these issues. STUDY SETTING: Published research evaluating Medicare coverage options in the United States. STUDY DESIGN: We considered key conceptual challenges and promising solutions that have been used thus far and suggest additional directions. DATA COLLECTION: Not available. PRINCIPAL FINDINGS: Many existing studies of MA versus TM include significant limitations, such as failing to account for unobserved confounders driving both beneficiary coverage choice and health outcomes once enrolled, not accounting for variation in benefit generosity, provider networks, or plan design across MA plans, and/or having been conducted at a time when MA enrollment was less than a third of all Medicare beneficiaries. We provide a review of methods that can help researchers to overcome these weaknesses and suggest additional methods and data sources that may aid future research. CONCLUSIONS: The MA program is becoming an essential part of the US healthcare system. By accounting for non-random movement into and out of MA and studying the heterogeneity of beneficiary experience across plan and market characteristics, researchers can provide the high-quality evidence necessary for policymakers to design the program and reform TM in ways that maximize beneficiary outcomes.
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Medicare Part C , Projetos de Pesquisa , Idoso , Humanos , Estados UnidosRESUMO
BACKGROUND: Medicare Advantage (MA) insurers use managed care techniques to review the utilization of medical services and control costs. It is unclear if MA enrollees have a lower utilization of elective surgical procedures such as inpatient hip and knee total joint arthroplasty (TJA), which have traditionally been covered by traditional Medicare (TM) without restrictions. METHODS: We conducted a cross-sectional study using a 20% sample of 2018 TM claims and MA encounter records for 5,300,188 TM enrollees and 1,970,032 MA enrollees who were 65 to 85 years of age. We calculated unadjusted and adjusted differences (controlling for beneficiary and market characteristics) in the incidence of TJA for MA compared with TM, and by MA plan type. Finally, we calculated differences in the time to contact with an orthopaedic surgeon and time to the surgical procedure among enrollees with an osteoarthritis diagnosis. RESULTS: After controlling for observable characteristics, there was a 15.6% lower incidence of TJA in MA enrollees compared with TM enrollees (p < 0.001). Compared with TM enrollees, health maintenance organization (HMO) enrollees were 28.1% less likely to undergo TJA, controlling for observable characteristics (p < 0.001). From the initial diagnosis, the time to contact with an orthopaedic surgeon and the time to the surgical procedure were also lower among TM enrollees compared with MA enrollees. At 2 years after an osteoarthritis diagnosis, 10.4% of TM enrollees, 7.9% of preferred provider organization (PPO) enrollees, and 5.7% of HMO enrollees had undergone inpatient TJA. CONCLUSIONS: MA coverage was associated with a lower utilization of elective, inpatient hip and knee TJA. MA was also associated with a longer time to orthopaedic surgeon evaluation and surgical procedure. LEVEL OF EVIDENCE: Prognostic Level III . See Instructions for Authors for a complete description of levels of evidence.
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Artroplastia do Joelho , Medicare Part C , Osteoartrite , Humanos , Idoso , Estados Unidos , Estudos Transversais , Programas de Assistência GerenciadaRESUMO
This Viewpoint discusses the potential benefits and harms of prior authorization in Medicare Advantage and the health policy implications and opportunities for improvement.
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Medicare Part C , Autorização Prévia , Melhoria de Qualidade , Medicaid , Medicare Part C/normas , Autorização Prévia/normas , Estados Unidos , Melhoria de Qualidade/normasRESUMO
BACKGROUND: The COVID-19 pandemic resulted in a novel challenge for healthcare delivery and implementation in the United States (US) in 2020 and beyond. Telemedicine arose as a significant and effective medium for safe and efficacious physician-patient interactions. Prior to the COVID-19 pandemic, telemedicine while available, had infrequently been utilized in pain medicine practices due to difficulties with reimbursement, the learning curve associated with new technology usage, and the need for new logistical systems in place to implement telemedicine effectively. Given the unique constraints on the healthcare system during the COVID-19 pandemic, the ubiquitous utilization of telemedicine among pain medicine physicians increased, giving insight into potential future roles for the technology beyond the pandemic. OBJECTIVES: To survey and understand the state of implementation of telemedicine into pain medicine practices across practice settings and geographical areas; to identify potential barriers to the implementation of telemedicine in pain medicine practice; and to identify the likelihood of telemedicine continuing beyond the pandemic in pain medicine practice. STUDY DESIGN: Online questionnaire targeting Pain Medicine physicians in the US. Participants were asked questions related to the use of telemedicine during the first peak of the COVID-19 pandemic. SETTING: Online-based questionnaire distributed to academic and private practice pain medicine physicians nationally in the United States. METHODS: A 34 web-based questionnaires were distributed by the American Society of Regional Anesthesia and Pain Medicine and the Spine Intervention Society to all active members. Data were analyzed using SAS v9.4. RESULTS: Between December 3, 2020, and February 18, 2021, 164 participants accessed the survey with a response rate of 14.3%. Overall, academic physicians were more likely to implement telemedicine than private practice physicians. Telemedicine was also more frequently utilized for follow-up appointments rather than initial visits. LIMITATIONS: Although our n = 164, the overall low response rate of 14.3% warrants further investigation into the utilization of telemedicine throughout the COVID-19 pandemic. CONCLUSIONS: Telemedicine as an emerging technology for efficient communication played a key role in mitigating the adverse effects of the COVID -19 pandemic on chronic pain patients. The utilization of telemedicine remarkably increased after the start of the pandemic within 1 to 2 weeks. Overall, private hospital-based centers were significantly less likely to implement telemedicine than academic centers, possibly due to limited access to secure telemedicine platforms and high start-up costs. Telemedicine was used more frequently for follow-up visits than initial visit encounters at most centers. In spite of the unforeseen consequences to the healthcare system and chronic pain practices in the US from COVID-19, telehealth has emerged as a unique model of care for patients with chronic pain. Although it has flaws, telehealth has the ability to increase access to care beyond the end of the pandemic. Further identification of barriers to the use of telemedicine platforms in private practices should be addressed from a policy perspective to facilitate increased care access.
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COVID-19 , Dor Crônica , Telemedicina , Analgésicos , Humanos , Pandemias , SARS-CoV-2 , Inquéritos e Questionários , Telemedicina/métodos , Estados UnidosRESUMO
BACKGROUND: Despite colostomy closure being a common procedure, it remains highly morbid. Previous literature suggests that complication rates, including surgical site infections, intra-abdominal abscess, and anastomotic failures, reach as high as 50%. With the creation of a dedicated colorectal service, colostomy reversals have been largely migrated from the acute care surgery services. This study analyzes the differences in outcomes in colostomy closures performed between colorectal surgeons and acute care surgeons. METHODS: We retrospectively analyzed our experience with 127 colostomy closures performed in our hospital system by acute care surgeons and colorectal surgeons from 2016 through 2020. Demographic data, operative data, and outcomes such as abscess formation, anastomotic leak, and readmission were analyzed. Multivariate regression analysis was performed for intraabdominal abscesses and anastomotic leaks. RESULTS: In total, 71 colostomy closures were performed by colorectal surgeons (56%) and 56 by acute care surgeons (43%). The majority of colostomy reversals were after Hartmann's procedure for perforated diverticulitis. No differences in demographics were identified, except for a shorter interval to closure in the acute care surgeons group (10.0 vs 7.2 months; P = .049). Two (3.6%) acute care surgeon patients required colorectal surgeon consultation during the definitive repair. Regression analysis identified body mass index (odds ratio 2.43; P = .001), male gender (odds ratio -2.39; P = .18), and colorectal surgeons (odds ratio -2.28; P = .025) as significant risk factors for anastomotic leak. CONCLUSION: Analysis of the current series identified female gender and increased body mass index as higher risk, while procedures performed by colorectal surgeons were at decreased risk for anastomotic leak. Our study identified colostomy reversals performed by a dedicated colorectal service decreased the rate of anastomotic leak.
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Anastomose Cirúrgica/efeitos adversos , Cirurgia Colorretal , Colostomia/efeitos adversos , Complicações Pós-Operatórias/epidemiologia , Adulto , Idoso , Feminino , Humanos , Tempo de Internação , Masculino , Pessoa de Meia-Idade , Análise de Regressão , Reoperação , Estudos Retrospectivos , Fatores de Risco , Centro Cirúrgico Hospitalar , Resultado do TratamentoRESUMO
OBJECTIVE: To examine the effects of parental Medicaid eligibility on parental health, parenting practices, and child development in low-income families. METHODS: Longitudinal analysis using data from the Early Child Longitudinal Study-Kindergarten: 2011 to 2016. Outcomes included parental self-rated health, parental depressive symptoms, parents' communication and warmth toward children, and children's social skills and externalizing and internalizing behaviors. We estimated 2-way (individual and year) fixed effects models using Medicaid eligibility as a continuous variable, controlling for changing economic conditions, changes in family structure, and state-specific trends. We then estimated triple difference models comparing lower income families to those with higher incomes. Finally, we estimated difference-in-difference models and used entropy weights in order to account for differences in trends prior to 2014 for some outcomes. RESULTS: In fixed effects models, expanding Medicaid eligibility by 100% of the federal poverty line is associated with a 12.7 percentage point reduction in parents' report of having fair or poor health (95% confidence interval [CI], -23.9, -1.5) and a 1.15-point improvement on a 12-point scale of parental warmth towards children (95% CI, 0.15, 2.16). Results were substantively similar in entropy-balanced difference-in-differences models. In triple difference models, expanded Medicaid eligibility is associated with a 0.46 point improvement in warmth (95% CI, 0.10, 0.83) but not improved parental health. No significant effects for child behavior or other outcomes were detected. CONCLUSIONS: Expanding Medicaid for parents may have implications for intergenerational family functioning that could lead to broader social benefits.
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Medicaid , Pais , Criança , Definição da Elegibilidade , Humanos , Estudos Longitudinais , Relações Pais-Filho , Poder Familiar , Estados UnidosRESUMO
Learning the true calorie content of fast food may induce consumers to change behavior, yet recent evidence is mixed on whether calorie labels cause consumers to order healthier meals. Especially for individuals for whom consumption of highly caloric fast-food is habitual, a rational response to calorie labeling may instead be to maintain consumption levels but increase physical activity. Using American Time Use Survey data from 2004 to 2012, we show that the 2008 New York City Calorie Labeling Mandate significantly improved several measures of physical activity, including overall metabolic equivalents of task units and minutes of sedentary activity. Our results translate to an average extra 28 calories burned per day or a 0.6 kg weight decrease for the average person over one year. These results provide a plausible mechanism for calorie labeling mandates to lower obesity rates, which we demonstrate in the New York City context.
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Rotulagem de Alimentos , Restaurantes , Ingestão de Energia , Fast Foods , Humanos , Obesidade/epidemiologiaRESUMO
Cigarette smokers earn significantly less than nonsmokers, but the magnitude of the smoking wage gap and the pathways by which it originates are unclear. Proposed mechanisms often focus on spot differences in employee productivity or employer preferences, neglecting the dynamic nature of human capital development and addiction. In this paper, we formulate a dynamic model of young workers as they transition from schooling to the labor market, a period in which the lifetime trajectory of wages is being developed. We estimate the model with data from the National Longitudinal Survey of Youth, 1997 Cohort, and we simulate the model under counterfactual scenarios that isolate the contemporaneous effects of smoking from dynamic differences in human capital accumulation and occupational selection. Results from our preferred model, which accounts for unobserved heterogeneity in the joint determination of smoking, human capital, labor supply, and wages, suggest that continued heavy smoking in young adulthood results in a wage penalty at age 30 of 15.9% and 15.2% for women and men, respectively. These differences are much smaller than the raw difference in means in wages at age 30. We show that the contemporaneous effect of heavy smoking net of any life-cycle effects explains 62.9% of the female smoking wage gap but only 20.4% of the male smoking wage gap.
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Salários e Benefícios , Fumar , Adolescente , Adulto , Escolaridade , Feminino , Humanos , Renda , Estudos Longitudinais , Masculino , Fumar/epidemiologia , Adulto JovemRESUMO
BACKGROUND: The existence of race and gender disparity has been described in numerous areas of medicine. The management of hepatocellular cancer is no different, but in no other area of medicine, is the treatment algorithm more complicated by local, regional, and national health care distribution policy. METHODS: Multivariate logistic regression and Cox-regression were utilized to analyze the treatment of patients with hepatocellular cancer registered in SEER between 1999 and 2013 to determine the incidence and effects of racial and gender disparity. Odd ratios (OR) are relative to Caucasian males, SEER region, and tumor characteristics. RESULTS: The analysis of 57,449 patients identified the minority were female (25.31%) and African-American (16.26%). All tumor interventions were protective (p < 0.001) with respect to survival. The mean survival for all registered patients was 13.01 months with conditional analysis, confirming that African-American men were less likely to undergo ablation, resection, or transplantation (p < 0.001). Women were more likely to undergo resection (p < 0.001). African-American women had an equivalent OR for resection but had a significantly lower transplant rate (p < 0.001). CONCLUSIONS: Utilizing SEER data as a surrogate for patient navigation in the treatment of hepatocellular cancer, our study identified not only race but gender bias with African-American women suffering the greatest. This is underscored by the lack of navigation of African-Americans to any therapy and a significant bias to navigate female patients to resection potentially limiting subsequent access to definitive therapy namely transplantation.
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Carcinoma Hepatocelular , Neoplasias Hepáticas , Carcinoma Hepatocelular/epidemiologia , Carcinoma Hepatocelular/cirurgia , Feminino , Humanos , Neoplasias Hepáticas/epidemiologia , Neoplasias Hepáticas/cirurgia , Masculino , Sistema de Registros , Programa de SEER , Sexismo , Estados Unidos/epidemiologiaRESUMO
BACKGROUND: Studies have demonstrated that there are sex disparities in the rate of liver transplantation. However, little is known statistically about whether this disparity is caused by liver compartment size, Model for End-Stage Liver Disease adjustments, or regional differences. METHODS: We use retrospective data from the United Network for Organ Sharing Standard Treatment Analysis and Research data files for liver transplantation from 1995 through 2012. The final sample consists of 150,149 patients. These data contain information on all individuals who registered for the liver transplant waiting list as well as updated outcome data. Linear probability and logistic regression models were both used. RESULTS: Women were 4.8 percentage points less likely to receive a transplant. Adjustment for race, weight, body mass index, region, education, and other characteristics attenuated the sex difference by roughly 19% (from 4.8 to 3.9 percentage points). The disparity was consistent across the 11 United Network for Organ Sharing allocation regions. Comparing the heaviest women to the lightest men, the disparity flipped. Pairwise comparisons between men and women of various sizes suggest that disparities in favor of men increase with the ratio of male-to-female size. CONCLUSION: Our results document persistent sex disparity in liver transplantation, only 19% of which is explained by size differentials between men and women. Differences in rates of transplantation are increasing in the ratio of male-to-female height and weight, suggesting that some of the disparity is explained by differences in liver compartment size.
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Disparidades em Assistência à Saúde/estatística & dados numéricos , Transplante de Fígado/estatística & dados numéricos , Pesos e Medidas Corporais , Doença Hepática Terminal/epidemiologia , Doença Hepática Terminal/cirurgia , Feminino , História do Século XX , História do Século XXI , Humanos , Transplante de Fígado/história , Masculino , Análise Multivariada , Estudos Retrospectivos , Fatores SexuaisRESUMO
Introduction: After promising early outcomes in the use of absorbable biologic mesh for complex abdominal wall reconstruction, significant criticism has been raised over the longevity of these repairs after its 2-year resorption profile. Methods: This is the long-term (5-year) follow-up analysis of our initial experience with the absorbable polymer scaffold poly-4-hydroxybutyrate (P4HB) mesh compared with a consecutive contiguous group treated with porcine cadaveric mesh for complex abdominal wall reconstructions. Our clinical analysis was performed using Stata 14.2 and Excel 16.16.23. Results: After a 5-year follow-up period, the P4HB group (n = 31) experienced lower rates of reherniation (12.9% vs 38.1%; P = 0.017) compared with the porcine cadaveric mesh group (n = 42). The median interval in months to recurrent herniation was similar between groups (24.3 vs 20.8; P = 0.700). Multivariate logistic regression analysis on long-term outcomes identified smoking (P = 0.004), African American race (P = 0.004), and the use of cadaveric grafts (P = 0.003) as risks for complication while smoking (P = 0.034) and the use of cadaveric grafts (P = 0.014) were identified as risks for recurrence. The long-term cost analysis showed that P4HB had a $10,595 per case costs savings over porcine cadaveric mesh. Conclusions: Our study identified the superior outcomes in clinical performance and a value-based benefit of absorbable biologic P4HB scaffold persisted after the 2-year resorption timeframe. Data analysis also confirmed the use of porcine cadaveric grafts independently contributed to the incidence of complications and recurrences.
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STUDY OBJECTIVES: To examine the cost-effectiveness and potential net monetary benefit (NMB) of a fully automated digital cognitive behavioral therapy (CBT) intervention for insomnia compared with no insomnia treatment in the United States (US). Similar relative comparisons were made for pharmacotherapy and clinician-delivered CBT (individual and group). METHODS: We simulated a Markov model of 100,000 individuals using parameters calibrated from the literature including direct (treatment) and indirect costs (e.g. insomnia-related healthcare expenditure and lost workplace productivity). Health utility estimates were converted into quality-adjusted life years (QALYs) and one QALY was worth $50,000. Simulated individuals were randomized equally to one of five arms (digital CBT, pharmacotherapy, individual CBT, group CBT, or no insomnia treatment). Sensitivity was assessed by bootstrapping the calibrated parameters. Cost estimates were expressed in 2019 US dollars. RESULTS: Digital CBT was cost beneficial when compared with no insomnia treatment and had a positive NMB of $681.06 (per individual over 6 months). Bootstrap sensitivity analysis demonstrated that the NMB was positive in 94.7% of simulations. Relative to other insomnia treatments, digital CBT was the most cost-effective treatment because it generated the smallest incremental cost-effectiveness ratio (-$3,124.73). CONCLUSIONS: Digital CBT was the most cost-effective insomnia treatment followed by group CBT, pharmacotherapy, and individual CBT. It is financially prudent and beneficial from a societal perspective to utilize automated digital CBT to treat insomnia at a population scale.
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Terapia Cognitivo-Comportamental , Distúrbios do Início e da Manutenção do Sono , Análise Custo-Benefício , Custos de Cuidados de Saúde , Humanos , Anos de Vida Ajustados por Qualidade de Vida , Distúrbios do Início e da Manutenção do Sono/terapia , Estados UnidosRESUMO
INTRODUCTION: The reported rate of postoperative bile leak is variable between 3 and 33%. Recent data would suggest a minimally invasive approach to liver surgery has decreased this incidence. METHODS: This multi-institutional case-control study utilized databases from three high-volume surgeons. All consecutive open and minimally invasive liver resection cases were analyzed in a propensity score-adjusted multivariable regression. A p value < 0.05 was considered significant. RESULTS: In 1388 consecutive liver resections, the average age was 56.9 ± 14.0 years, 730 (52.59%) were male gender, and 599 (43.16%) underwent minimally invasive liver resection. Thirty-nine (2.81%) in the series were identified with post-resection bile duct leaks. Leaks were associated with major resections and increased blood loss (p < 0.05). Propensity score-adjusted multivariable regression identified minimally invasive liver resection significantly and independently reduced the odds of bile duct leak (OR 0.48, p = 0.046) even controlling for BMI, ASA, cirrhosis, major resection, and resection year. CONCLUSIONS: Our data suggest the incidence of bile leaks in a large-volume center series is far less than previously reported and that a minimally invasive approach to liver resection reduces the incidence of postoperative bile leak.
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Ductos Biliares/cirurgia , Bile , Hepatectomia/efeitos adversos , Complicações Pós-Operatórias/etiologia , Adulto , Idoso , Perda Sanguínea Cirúrgica , Estudos de Casos e Controles , Feminino , Hepatectomia/métodos , Humanos , Laparoscopia/efeitos adversos , Masculino , Pessoa de Meia-Idade , Procedimentos Cirúrgicos Minimamente Invasivos/efeitos adversos , Análise Multivariada , Pontuação de Propensão , Fatores de Proteção , Análise de RegressãoRESUMO
BACKGROUND: Bile duct injury during laparoscopic cholecystectomy persists as a significant problem in general surgery, resulting in complex injuries, arterial damage, and post repair strictures. METHODS: We performed a retrospective analysis between 2 eras of bile duct injury repairs: 1987 to 2001 (n = 58) and 2002 to 2016 (n = 52) using logistic regression analyses to assess presentation, repair complexity, and outcomes. RESULTS: No differences in demographics, incidence of cholecystitis, conversion, time to presentation, level of injury, or arterial injury were identified. The second era had an increase in patient age, transhepatic catheter use, prior repair, and utilization of complex repairs. This approach resulted in equivalent complications and mortality rates with increased resource utilization but a lesser incidence of post-repair strictures (P = .004). Regression modeling correlated strictures to prior operative repairs (OR 4.25; P = .016) and a protective effect of repairs performed in the second era (OR 0.23; P = .045). CONCLUSION: The second era identified a decreasing trend of attempted repairs by referring surgeons but an increase in transhepatic catheters and complex repairs resulting in lesser rates of post-repair stricture. Final regression modeling confirmed increased operative experience decreased post-repair stricture reaffirming the benefits of early identification and referral of bile duct injuries to an experienced hepatobiliary surgeon at a specialty center.
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Ductos Biliares/lesões , Colecistectomia Laparoscópica/efeitos adversos , Doença Iatrogênica/epidemiologia , Complicações Intraoperatórias/cirurgia , Adulto , Idoso , Ductos Biliares/cirurgia , Colecistectomia Laparoscópica/métodos , Estudos de Coortes , Bases de Dados Factuais , Feminino , Seguimentos , Humanos , Incidência , Complicações Intraoperatórias/diagnóstico por imagem , Imageamento por Ressonância Magnética/métodos , Masculino , Pessoa de Meia-Idade , Reoperação/métodos , Estudos Retrospectivos , Medição de Risco , Centros de Atenção Terciária , Tomografia Computadorizada por Raios X/métodos , Resultado do TratamentoRESUMO
BACKGROUND: Immunosuppression is a known risk for post-transplant infections. Little data exist on the risk contributions of specific agents for various infections. METHODS: A triply robust propensity score-adjusted analysis was performed in a renal transplant cohort between February 2006 and January 2014. The study was performed to identify the incidence and the risk factors for developing a post-transplant infection. After initial bivariate analysis, a triply robust propensity score-adjusted multivariate logistic regression was performed. RESULTS: The mean age of the 717 renal transplant recipients was 50.0 ± 13.3 years, with the majority being male (61.6%) and 349 (48.7%) experiencing at least 1 post-transplant infection. Neither race, graft type, nor insurance status was associated with an increased incidence or risk of infection. In a fully adjusted regression model, the immunosuppressants mycophenolic acid mofetil (OR 0.38, 95% CI 0.21-0.71; P < .001) and alemtuzumab (OR 0.40, 95% CI 0.19-0.85; Pâ¯=â¯.020) were protective. CONCLUSION: Alemtuzumab and mycophenolic acid mofetil as immunosuppressant agents in a multiagent protocol appear to decrease the incidence of infection. Cytomegalovirus antigenemia was the greatest risk for infection and mycophenolic acid mofetil possessed the greatest protective effect on viral infections.
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Alemtuzumab/efeitos adversos , Imunossupressores/efeitos adversos , Infecções/etiologia , Transplante de Rim/efeitos adversos , Ácido Micofenólico/efeitos adversos , Viroses/etiologia , Adulto , Estudos de Casos e Controles , Infecções Comunitárias Adquiridas/etiologia , Infecção Hospitalar/etiologia , Feminino , Glucocorticoides/efeitos adversos , Humanos , Infecções/microbiologia , Masculino , Pessoa de Meia-Idade , Infecções Oportunistas/etiologia , Pontuação de Propensão , Estudos Retrospectivos , Fatores de Risco , Tacrolimo/efeitos adversos , Viroses/virologiaRESUMO
BACKGROUND: Sources of liver transplant disparities are not understood adequately, particularly in terms of race and region. METHODS: Fixed effects multivariate logistic regression augmented by modified forward and backward stepwise regression of transplanted patients from the United Network for Organ Sharing Standard Transplant Analysis and Research database (1985-2016) was performed to assess causal inference of such disparities. RESULTS: In the study sample (N = 258,602), significant disparities in the odds of receiving a liver were found: African Americans odds ratio 1.12 (95% confidence interval, 1.08-1.17), Asians 1.12 (95% confidence interval, 1.07-1.18), females 0.80 (95% confidence interval, 0.78-0.83), and malignancy 1.18 (95% confidence interval, 1.13-1.22). Region 7 (IL, MN, ND, SD, and WI) was set as the reference level since its transplantation rate most closely approximated the sex and race-matched rate of the national post-Share 35 average. Significant racial disparities by region were identified using Caucasian Region 7 as the reference: Hispanic Region 9 (New York, West Vermont) 1.22 (1.02-1.45), Hispanic Region 1 (New England) 1.26 (1.01-1.57), Hispanic Region 4 (Oklahoma, TX) 1.23 (1.05-1.43), and Asian Region 4 (Oklahoma, TX) 1.35 (1.05-1.73). CONCLUSION: Despite numerous adjustments to liver allocation, we identified with causal inference statistics on a large dataset spanning ≥30 years there remain racial and regional overweighting.
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Etnicidade/estatística & dados numéricos , Disparidades em Assistência à Saúde/etnologia , Transplante de Fígado , Obtenção de Tecidos e Órgãos , População Branca/estatística & dados numéricos , Adulto , Idoso , Feminino , Humanos , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Estados Unidos , Listas de EsperaRESUMO
Many public health policies are rooted in findings from medical and epidemiological studies that fail to consider behavioral influences. Using nearly 50 years of data from Framingham Heart Study male participants, we evaluate the longevity consequences of different lifetime smoking patterns by jointly estimating smoking behavior and health outcomes over the life cycle, by richly including smoking and health histories, and by flexibly incorporating correlated unobserved heterogeneity. Unconditional difference-in-mean calculations that treat smoking behaviors as random indicate a 9.3 year difference in age of death between lifelong smokers and nonsmokers; our findings suggest the bias-corrected difference is 4.3 years.
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BACKGROUND: Racial disparity in access to liver transplantation among African Americans (AA) compared to Caucasians (CA) has been well described. The aim of this investigation was to examine the presentation of AA liver transplant recipients in a socioeconomically challenged region. METHODS: 680 adult liver transplant candidates and 233 resultant recipients between 2007 and 2015 were analyzed using univariate and multivariate analyses to evaluate factors significant for transplantation. RESULTS: Percentages of wait list patients transplanted were similar between CA and AA (34.9% vs. 32.2%, p = 0.5205). AA were younger (50.4 ± 1.8 vs. 56.3 ± 0.7 yrs, p = 0.0003) with higher average MELD scores (22.9 ± 1.6 vs. 19.4 ± 0.7, p = 0.0230). Overall patient mortality was similar (AA 22.7% vs. CA 26.3%, p = 0.5931). A multiple linear regression showed that male gender was strongly associated with transplantation. CONCLUSIONS: Equal access to liver transplantation remains challenging for racial minorities. At our institution, AA were accepted and transplanted at an equivalent rate as CA despite a higher AA population, HCV rate and diagnosed HCC. AA were younger and sicker at the time of transplant, but overall had similar outcomes compared to CA. Our study highlights the need for studies to delineate the underpinnings of disparity in transplantation access.