Cohort design to assess the association between post-hospital primary care physician follow-up visits and hospital readmissions.

While multifaceted post-hospitalization interventions can succeed in preventing hospital readmissions, many of these interventions are labor-intensive and costly. We hypothesized that a timely post-discharge primary care physician (PCP) visit alone might prevent hospital readmission. We conducted a retrospective cohort study to assess whether post-hospitalization PCP visits within 14 days of discharge were associated with lower rates of 30-day hospital readmission. In a secondary analysis we also assessed: whether visits with a PCP at 7-days post-discharge changed rates of hospital readmissions and whether post-hospitalization PCP visits were associated with decreased 90-day hospital readmissions. We included all adults with a PCP who were discharged from an inpatient medical service in a large, urban integrated academic health system from January 1, 2019 to September 9, 2019 in our analysis. We performed unadjusted bivariate analyses to measure the associations between having a PCP visit within 14 and 7 days of discharge and hospital readmission within 30 and 90 days. Then we constructed multivariate logistic regression models including patient medical and utilization characteristics to estimate the adjusted odds of a patient with a post-hospitalization PCP visit experiencing a 30-day hospital readmission (primary outcome) and 90-day readmission (secondary outcome). A total of 9236 patients were discharged; mean age was 57.9 years and 59.7% were female. Of the study population, 35.6% (n = 3284) and 24.1% (n = 2224) of patients had a post-hospitalization PCP visit within 14 days and or 7 days, respectively. Overall, 1259 (13.6%) and 2153 (23.3%) of discharged patients were readmitted at 30 and 90 days, respectively. In unadjusted analyses, having a post discharge PCP visit was not associated with decreased hospital readmission rates, but after adjusting for sociodemographic, medical and utilization characteristics, having a post-hospitalization PCP visit at 14 and 7 days was associated with lower hospital readmission rates at 30 days: 0.68 (95% CI 0.59-0.79) and 0.76 (95% CI 0.66-0.89), respectively; and 90 days: 0.76 (95% CI 0.68-0.85) and 0.80 (95% CI 0.70-0.91), respectively. In this large integrated urban academic health system, having a post-hospitalization PCP visit within 14- and 7-days of hospital discharge was associated with lower rates of readmission at 30 and 90 days. Further studies should examine whether improving access to PCP visits post hospitalization reduces readmissions rates.

Impact of frailty on mortality and quality of life in patients with a history of cancer undergoing transcatheter aortic valve replacement.

BACKGROUND: Transcatheter aortic valve replacement (TAVR) is increasingly offered for aortic stenosis (AS) treatment in patients with a history of cancer. The impact of frailty on outcomes in this specific patient population is not well described. HYPOTHESIS: Frailty is associated with mortality and poorer quality of life (QOL) outcomes in patients undergoing TAVR with a history of cancer. METHODS: This retrospective single center cohort study included AS patients who underwent TAVR from August 1, 2012 to May 15, 2020. Frailty was measured using serum albumin, hemoglobin, gait speed, functional dependence, and cognitive impairment. The primary outcome was a composite of all-cause mortality and QOL at 1 year. A poor primary outcome was defined as either all-cause mortality, Kansas City Cardiomyopathy Questionnaire overall summary (KCCQ-OS) score <45 or a KCCQ-OS score decline of ≥10 points from baseline. Regression analysis was used to determine the impact of frailty on the primary outcome. RESULTS: The study population was stratified into active/recent cancer (n = 107), remote cancer (n = 85), and non-cancer (n = 448). Univariate analysis of each cohort showed that frailty was associated with the primary outcome only in the non-cancer cohort (p = .004). Multivariate analysis showed that cancer history was not associated with a poor primary outcome, whereas frailty was (1.7 odds ratio, 95% confidence interval [CI]: 1.1-2.8; p = .028). CONCLUSIONS: Frailty is associated with mortality and poor QOL in the overall and non-cancer cohorts. Further investigation is warranted to understand frailty's effect on the cancer population. Frailty should be heavily considered during TAVR evaluation.

"Teach-to-Goal" to Better Assess Informed Consent Comprehension among Incarcerated Clinical Research Participants.

Correctional health research requires important safeguards to ensure that research participation is ethically conducted. In addition to having disproportionately low educational attainment and low literacy, incarcerated people suffer from health-related conditions that can affect cognition (e.g., traumatic brain injury, substance use disorders, mental illness). Yet modified informed consent processes that assess participants' comprehension of the risks and benefits of participation are not required by relevant federal guidelines. A push to assess comprehension of informed consent documents is particularly timely given an increase in demand for correctional health research in the context of criminal justice reform. We argue that comprehension assessments can identify persons who should be excluded from research and help those who will ultimately participate in studies better understand the risks and benefits of their participation.

Detained and Distressed: Persistent Distressing Symptoms in a Population of Older Jail Inmates.

Distressing symptoms are associated with poor function, acute care use, and mortality in older adults. The number of older jail inmates is increasing rapidly, prompting calls to develop systems of care to meet their healthcare needs, yet little is known about multidimensional symptom burden in this population. This cross-sectional study describes the prevalence and factors associated with distressing symptoms and the overlap between different forms of symptom distress in 125 older jail inmates in an urban county jail. Physical distress was assessed using the Memorial Symptom Assessment Scale. Several other forms of symptom distress were also examined, including psychological (Generalized Anxiety Disorder Scale, Patient Health Questionnaire), existential (Patient Dignity Inventory), and social (Three Item Loneliness Scale). Information was collected on participant sociodemographic characteristics, multimorbidity, serious mental illness (SMI), functional impairment, and behavioral health risk factors through self-report and chart review. Chi-square tests were used to identify factors associated with physical distress. Overlap between forms of distress was evaluated using set theory analysis. Overall, many participants (74%) reported distressing symptoms, including having one or more physical (44%), psychological (37%), existential (54%), or social (45%) symptoms. Physical distress was associated with poor health (multimorbidity, functional impairment, SMI) and low income. Of the 93 participants with any symptom, 49% reported three or more forms of distress. These findings suggest that an optimal model of care for this population would include a geriatrics-palliative care approach that integrates the management of all forms of symptom distress into a comprehensive treatment paradigm stretching from jail to the community.

The state of research funding from the National Institutes of Health for criminal justice health research.

BACKGROUND: Over 20 million Americans are currently or have been incarcerated. Most are from medically underserved populations; 1 in 3 African American men and 1 in 6 Latino men born in 2001 are projected to go to prison during their lifetime. The amount of funding from the National Institutes of Health (NIH) to understand and improve the health of persons involved with the criminal justice system is unknown. OBJECTIVE: To describe NIH funding for research on the health and health care needs of criminal justice-involved persons. DESIGN: Review of NIH grants (2008-2012) in the RePORT (Research Portfolio Online Reporting Tools) database. SETTING: U.S. criminal justice system. PATIENTS: Criminal justice-involved persons participating in NIH-funded clinical research. MEASUREMENTS: NIH research and training grants awarded, by number, type, research area, institute or center, and dollar amount. RESULTS: Of more than 250 000 NIH-funded grants, 180 (<0.1%) focused on criminal justice health research. The 3 most common foci were substance use or HIV (64%), mental health (11%), and juvenile health (8%). The National Institute on Drug Abuse and the National Institute of Mental Health funded 78% of all grants. In 2012, the NIH invested $40.9 million in criminal justice health research, or 1.5% of the $2.7 billion health disparities budget for that year. LIMITATION: NIH-supported research that did not explicitly include current or former prisoners but may have relevance to criminal justice health was not included. CONCLUSION: Federal funding for research focused on understanding and improving the health of criminal justice-involved persons is small, even compared with the NIH's overall investment in health disparities research. The NIH is well-positioned to transform the care of current and former prisoners by investing in this critical yet overlooked research area.