Estimating the effect of dialysis staffing ratio regulations on mortality and hospitalizations for Medicare hemodialysis patients.

BACKGROUND AND OBJECTIVES: Eight states and Washington, DC have implemented regulations mandating a minimum ratio between treatment staff and patients receiving hemodialysis in a facility in an effort to improve the quality of hemodialysis treatment. Our investigation examines the association between minimum staffing regulations and patient mortality for four states and hospitalizations for two states that implemented these rules during our sample period. DESIGN, SETTING, PARTICIPANTS, AND MEASUREMENTS: We utilized a synthetic difference in differences estimation to analyze the effect of minimum staffing ratios on hemodialysis treatment quality, measured by deaths and hospitalizations for end-stage renal disease patients. We used data gathered by the US Renal Data System and aggregated at the state level. RESULTS: We are unable to find evidence that mandated dialysis staffing ratios area associated with a reduction in mortality or hospitalizations. We estimate a slight reduction in deaths per 1000 patient hours and a slight increase in hospitalizations, but neither are statistically significant. CONCLUSIONS: We were unable to find evidence that minimum staffing ratios for hemodialysis facilities are associated with improved patient outcomes. Our findings highlight the need for future work, studying the impact of these regulations at the facility level.

Post-acute health care burden after SARS-CoV-2 infection: A retrospective cohort study among 530,892 adults

ImportanceThe SARS-CoV-2 pandemic portends a significant increase in health care use related to post-acute COVID sequelae, but the magnitude is not known. ObjectiveTo assess the burden of post-acute health care use after a positive versus negative polymerase chain reaction (PCR) test for SARS-CoV-2. Design, Setting, and ParticipantsRetrospective cohort study of community-dwelling adults January 1, 2020 to March 31, 2021 in Ontario, Canada, using linked population-based health data. Follow-up began 56 days after PCR testing. ExposuresIndividuals with a positive SARS-CoV-2 PCR test were matched 1:1 to individuals who tested negative based on hospitalization, test date, public health unit, sex, and a propensity score of socio-demographic and clinical characteristics. Main Outcomes and MeasuresThe health care utilization rate was the number of outpatient clinical encounters, homecare encounters, emergency department visits, days hospitalized, and days in long-term care per person-year. Mean health care utilization for test-positive versus negative individuals was compared using negative binomial regression, and rates at 95th and 99th percentiles were compared. Outcomes were also stratified by sex. ResultsAmong 530,232 unique, matched individuals, mean age was 44 years (sd 17), 51% were female, and 0.6% had received [≥]1 COVID-19 vaccine dose. The mean rate of health care utilization was 11% higher in test-positive individuals (RR 1.11, 95% confidence interval [CI] 1.10-1.13). At the 95th percentile, test-positive individuals had 2.1 (95% CI 1.5-2.6) more health care encounters per person-year, and at the 99th percentile 71.9 (95% CI 57.6-83.2) more health care encounters per person-year. At the 95th percentile, test-positive women had 3.8 (95% CI 2.8-4.8) more health care encounters per person-year while there was no difference for men. At the 99th percentile, test-positive women had 76.7 (95% CI 56.3-89.6) more encounters per person-year, compared to 37.6 (95% CI 16.7-64.3) per person-year for men. Conclusions and RelevancePost-acute health care utilization after a positive SARS-CoV-2 PCR test is significantly higher compared to matched test-negative individuals. Given the number of infections worldwide, this translates to a tremendous increase in use of health care resources. Stakeholders can use these findings to prepare for health care demand associated with long COVID. Key PointsO_ST_ABSQuestionC_ST_ABSHow does the burden of health care use [≥]56 days after a positive SARS-CoV-2 polymerase chain reaction (PCR) test compare to matched individuals who tested negative? FindingsAfter accounting for multiple factors, the mean burden of post-acute health care use was 11% higher among those who tested positive, with higher rates of outpatient encounters, days hospitalized, and days in long-term care. Rates of homecare use were higher for test-positive women but lower for men. For perspective, for every day in January 2022 with 100,000 or more infections, this translates to an estimated 72,000 additional post-acute health care encounters per year for the 1% of people who experienced the most severe complications of SARS-CoV-2; among those in the top 50% of health care use, this translates to 245,000 additional health care encounters per year. This increase will occur in the context of an ongoing pandemic and, in many health care systems, a depleted workforce and backlogs of care. Unless addressed, this increase is likely to exacerbate existing health inequities. MeaningGiven the large number of people infected, stakeholders can use these findings to plan for health care use associated with long COVID.

Clinical Risk, Sociodemographic Factors, and SARS-CoV-2 Infection Over Time in Ontario, Canada

BackgroundSociodemographic and clinical factors are emerging as important predictors for developing severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. ObjectiveTo determine whether public health interventions that culminated in a stay-at-home lockdown instituted during the first wave of the pandemic in March/April 2020 were effective at mitigating the association of any of these factors with the risk of infection. DesignPopulation-based cohort study SettingOntario, Canada PatientsAll adults that underwent testing for SARS-CoV-2 between January 1 and June 12, 2020. MeasurementsThe outcome of interest was SARS-CoV-2 infection, determined by reverse transcription polymerase chain reaction testing. Adjusted odds ratios (ORs) were determined for sociodemographic and clinical risk factors before and after the peak of the pandemic to assess for changes in effect sizes. ResultsAmong 578,263 community-dwelling individuals, 20,524 (3.5%) people tested positive. The association between age and SARS-CoV-2 infection risk among tested community-dwelling individuals varied over time (P-interaction <0.0001). Prior to the first-wave peak of the pandemic, the likelihood of SARS-CoV-2 infection increased progressively with age compared with individuals aged 18-45 years (P<0.0001). This association subsequently reversed, with all age groups younger than 85 years at progressively higher risk of infection (P<0.0001) after the peak. Otherwise, risk factors that persisted throughout included male sex, residing in lower income neighborhoods, residing in more racially/ethnically diverse communities, immigration to Canada, and history of hypertension and diabetes. While there was a reduction in infection rates across Ontario after mid-April, there was less impact in regions with higher degrees of racial/ethnic diversity. When considered in an additive risk model, following the initial peak of the pandemic, individuals living in the most racially/ethnically diverse communities with 2, 3, or [≥]4 risk factors had ORs of 1.89, 3.07, and 4.73-fold higher for SARS-CoV-2 infection compared to lower risk individuals in their community (all P<0.0001). In contrast, in the least racially/ethnically diverse communities, there was little to no gradient in infection rates across risk strata. ConclusionAfter public health interventions in March/April 2020, people with multiple risk factors residing in the most racially diverse communities of Ontario continued to have the highest likelihood of SARS-CoV-2 infection while risk was mitigated for people with multiple risk factors residing in less racially/ethnically diverse communities. Further efforts are necessary to reduce the risk of SARS-CoV-2 infection among the highest risk individuals residing in these communities. Primary Funding SourceCanadian Institutes of Health Research and the Ted Rogers Centre for Heart Research.

Estimating the effect of New Jersey's 2005 administrative nurse mandate on mortality and hospitalizations for medicare hemodialysis patients.

BACKGROUND AND OBJECTIVES: In 2005, the New Jersey Department of Health enacted a rule requiring that an administrator or designate always be present in a hemodialysis clinic and that the individual may not be involved in patient care activities at any time. Our investigation examines the effect of this unique rule on patient mortality and hospitalizations and is meant to inform the public policy discussion. DESIGN, SETTING, PARTICIPANTS, AND MEASUREMENTS: We utilized a synthetic control estimation to analyze the effect of this rule on patient mortality in New Jersey. We also compared trends for hospitalizations in New Jersey to other similar states. RESULTS: We find no evidence that the law affected patient mortality or the number of hospitalizations for Medicare patients in New Jersey. CONCLUSIONS: The New Jersey law poses substantial costs to hemodialysis clinics and we find little evidence of any measurable benefit to patients.

Living alone and cardiovascular disease outcomes.

OBJECTIVE: To evaluate cardiovascular (CV) outcomes in outpatients with coronary artery disease (CAD) living alone compared with those living with others. METHODS: The prospeCtive observational LongitudinAl RegIstry oF patients with stable coronarY artery disease (CLARIFY) included outpatients with stable CAD. CLARIFY enrolled participants in 45 countries from November 2009 to July 2010, with 5 years of follow-up. Living arrangement was documented at baseline. The primary outcome was a composite of major adverse cardiovascular events (MACEs) defined as CV death, myocardial infarction (MI) and stroke. RESULTS: Among 32 367 patients, 3648 patients were living alone (11.3%). After multivariate adjustment, there were no residual differences in MACE among patients living alone compared with those living with others (HR 1.04, 95% CI 0.92 to 1.18, p=0.52); however, there was significant heterogeneity in the exposure effect by sex (Pinteraction<0.01). Specifically, men living alone were at higher risk for MACE (HR 1.17, 95% CI 1.002 to 1.36, p=0.047) as opposed to women living alone (HR 0.82, 95% CI 0.65 to 1.04, p=0.1), predominantly driven by a heterogeneous effect by sex on MI (Pinteraction=0.006). There was no effect modification for MACE by age group (Pinteraction=0.3), although potential varying effects by age for MI (Pinteraction=0.046) and stroke (Pinteraction=0.05). CONCLUSIONS: Living alone was not associated with an independent increase in MACE, although significant sex-based differences were apparent. Men living alone may have a worse prognosis from CV disease than women; further analyses are needed to elucidate the mechanisms underlying this difference. TRIAL REGISTRATION NUMBER: ISRCTN43070564.