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OBJECTIVE: Bariatric surgery leads to substantial improvements in weight and weight-related conditions, but prior literature on post-surgical health expenditures is equivocal. In a retrospective cohort study, we compared expenditures between surgical and matched non-surgical patients. SUMMARY BACKGROUND DATA AND METHODS: In a retrospective study, total, outpatient, inpatient and medication expenditures 3 years before and 5.5 years after surgery were compared between 22,698 bariatric surgery (n=7,127 RYGB, 15,571 sleeve gastrectomy) patients from 2012-2019 and 66,769 matched non-surgical patients, using generalized estimating equations. We also compared expenditures between patients receiving the two leading surgical procedures in weighted analyses. RESULTS: Surgical and non-surgical cohorts were well matched, 80-81% female, with mean body mass index (BMI) of 44, and mean age of 47 (RYGB) and 44 (SG) years. Estimated total expenditures were similar between surgical and non-surgical groups 3 years before surgery ($27 difference, 95% confidence interval (CI): -42, 102)), increased 6 months prior to surgery for surgical patients, and decreased below pre-period levels for both groups after 3-5.5 years to become similar (difference at 5.5 y=-$61, 95% CI: -166, 52). Long-term outpatient expenditures were similar between groups. Surgical patients' lower long-term medication expenditures ($314 lower at 5.5 y, 95% CI: -419, -208) were offset by a higher risk of hospitalization. Total expenditures were similar between RYGB and SG patients 3.5 to 5.5 years after surgery. CONCLUSIONS: Bariatric surgery translated into lower medication expenditures than matched controls, but not lower overall long-term expenditures. Expenditure trends appear similar for the two leading bariatric operations.
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BACKGROUND: Neuropsychiatric symptoms affect the majority of dementia patients. Past studies report high rates of potentially inappropriate prescribing of psychotropic medications in this population. We investigate differences in neuropsychiatric diagnoses and psychotropic medication prescribing in a local US cohort by sex and race. METHODS: We utilize Medicare claims and prescription fill records in a cohort of 100% Medicare North and South Carolina beneficiaries ages 50 and above for the year 2017 with a dementia diagnosis. We identify dementia and quantify diagnosis of anxiety, depression and psychosis using validated coding algorithms. We search Medicare claims for antianxiety, antidepressant and antipsychotic medications to determine prescriptions filled. RESULTS: Anxiety and depression were diagnosed at higher rates in White patients; psychosis at higher rates in Black patients. (P < .001) Females were diagnosed with anxiety, depression and psychosis at higher rates than males (P < .001) and filled more antianxiety and antidepressant medications than males. (P < .001) Black and Other race patients filled more antipsychotic medications for anxiety, depression and psychosis than White patients. (P < .001) Antidepressants were prescribed at higher rates than antianxiety or antipsychotic medications across all patients and diagnoses. Of patients with no neuropsychiatric diagnosis, 11.4% were prescribed an antianxiety medication, 22.8% prescribed an antidepressant and 7.6% prescribed an antipsychotic. CONCLUSIONS: The high fill rate of antianxiety (benzodiazepine) medications in dementia patients, especially females is a concern. Patients are prescribed psychotropic medications at high rates. This practice may represent potentially inappropriate prescribing. Patient/caregiver education with innovative community outreach and care delivery models may help decrease medication use.
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BACKGROUND: Evaluation of Medicare-Medicaid integration models' effects on patient-centered outcomes and costs requires multiple data sources and validated processes for linkage and reconciliation. OBJECTIVE: To describe the opportunities and limitations of linking state-specific Medicaid and Centers for Medicare & Medicaid Services administrative claims data to measure patient-centered outcomes for North Carolina dual-eligible beneficiaries. RESEARCH DESIGN: We developed systematic processes to (1) validate the beneficiary ID linkage using sex and date of birth in a beneficiary ID crosswalk, (2) verify dates of dual enrollment, and (3) reconcile Medicare-Medicaid claims data to support the development and use of patient-centered outcomes in linked data. PARTICIPANTS: North Carolina Medicaid beneficiaries with full Medicaid benefits and concurrent Medicare enrollment (FBDE) between 2014 and 2017. MEASURES: We identified need-based subgroups based on service use and eligibility program requirements. We calculated utilization and costs for Medicaid and Medicare, matched Medicaid claims to Medicare service categories where possible, and reported outcomes by the payer. Some services were covered only by Medicaid or Medicare, including Medicaid-only covered home and community-based services (HCBS). RESULTS: Of 498,030 potential dual enrollees, we verified the linkage and FBDE eligibility of 425,664 (85.5%) beneficiaries, including 281,174 adults enrolled in Medicaid and Medicare fee-for-service. The most common need-based subgroups were intensive behavioral health service users (26.2%) and HCBS users (10.8%) for adults under age 65, and HCBS users (20.6%) and nursing home residents (12.4%) for adults age 65 and over. Medicaid funded 42% and 49% of spending for adults under 65 and adults 65 and older, respectively. Adults under 65 had greater behavioral health service utilization but less skilled nursing facility, HCBS, and home health utilization compared with adults 65 and older. CONCLUSIONS: Linkage of Medicare-Medicaid data improves understanding of patient-centered outcomes among FBDE by combining Medicare-funded acute and ambulatory services with Medicaid-funded HCBS. Using linked Medicare-Medicaid data illustrates the diverse patient experience within FBDE beneficiaries, which is key to informing patient-centered outcomes, developing and evaluating integrated Medicare and Medicaid programs, and promoting health equity.
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Serviços de Assistência Domiciliar , Medicaid , Adulto , Humanos , Idoso , Estados Unidos , Medicare , Custos e Análise de Custo , Avaliação de Resultados da Assistência ao PacienteRESUMO
BACKGROUND: Medicare claims and electronic health record data are both commonly used for research and clinical practice improvement; however, it is not known how concordant diagnoses of neurodegenerative diseases (NDD, comprising dementia and Parkinson's disease) are in these data types. Therefore, our objective was to determine the sensitivity and specificity of neurodegenerative disease (NDD) diagnoses contained in structured electronic health record (EHR) data compared to Medicare claims data. METHODS: This was a retrospective cohort study of 101,980 unique patients seen at a large North Carolina health system between 2013-2017, which were linked to 100% North and South Carolina Medicare claims data, to evaluate the accuracy of diagnoses of neurodegenerative diseases in EHRs compared to Medicare claims data. Patients age > 50 who were enrolled in fee-for-service Medicare were included in the study. Patients were classified as having or not having NDD based on the presence of validated ICD-CM-9 or ICD-CM-10 codes associated with NDD or claims for prescription drugs used to treat NDD. EHR diagnoses were compared to Medicare claims diagnoses. RESULTS: The specificity of any EHR diagnosis of NDD was 99.0%; sensitivity was 61.3%. Positive predictive value and negative predictive value were 90.8% and 94.1% respectively. Specificity of an EHR diagnosis of dementia was 99.0%, and sensitivity was 56.1%. Specificity of an EHR diagnosis of PD was 99.7%, while sensitivity was 76.1%. CONCLUSIONS: More research is needed to investigate under-documentation of NDD in electronic health records relative to Medicare claims data, which has major implications for clinical practice (particularly patient safety) and research using real-world data.
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Demência , Doenças Neurodegenerativas , Doença de Parkinson , Estados Unidos/epidemiologia , Humanos , Idoso , Doença de Parkinson/diagnóstico , Doença de Parkinson/epidemiologia , Registros Eletrônicos de Saúde , Medicare , Estudos Retrospectivos , Demência/diagnóstico , Demência/epidemiologiaRESUMO
BACKGROUND: To determine if neighborhood socioeconomic deprivation independently predicts 30-day mortality and readmission for patients with sepsis or critical illness after adjusting for individual poverty, demographics, comorbidity burden, access to healthcare, and characteristics of treating healthcare facilities. METHODS: We performed a nationwide study of United States Medicare beneficiaries from 2017 to 2019. We identified hospitalized patients with severe sepsis and patients requiring prolonged mechanical ventilation, tracheostomy, or extracorporeal membrane oxygenation (ECMO) through Diagnosis Related Groups (DRGs). We estimated the association between neighborhood socioeconomic deprivation, measured by the Area Deprivation Index (ADI), and 30-day mortality and unplanned readmission using logistic regression models with restricted cubic splines. We sequentially adjusted for demographics, individual poverty, and medical comorbidities, access to healthcare services; and characteristics of treating healthcare facilities. RESULTS: A total of 1,526,405 admissions were included in the mortality analysis and 1,354,548 were included in the readmission analysis. After full adjustment, 30-day mortality for patients was higher for those from most-deprived neighborhoods (ADI 100) compared to least deprived neighborhoods (ADI 1) for patients with severe sepsis (OR 1.35 95% [CI 1.29-1.42]) or with prolonged mechanical ventilation with or without sepsis (OR 1.42 [95% CI 1.31, 1.54]). This association was linear and dose dependent. However, neighborhood socioeconomic deprivation was not associated with 30-day unplanned readmission for patients with severe sepsis and was inversely associated with readmission for patients requiring prolonged mechanical ventilation with or without sepsis. CONCLUSIONS: A strong association between neighborhood socioeconomic deprivation and 30-day mortality for critically ill patients is not explained by differences in individual poverty, demographics, measured baseline medical risk, access to healthcare resources, or characteristics of treating hospitals.
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Estado Terminal , Sepse , Humanos , Idoso , Estados Unidos/epidemiologia , Estado Terminal/terapia , Readmissão do Paciente , Medicare , Fatores Socioeconômicos , Acessibilidade aos Serviços de Saúde , Sepse/terapiaRESUMO
INTRODUCTION: Racial/ethnic disparities exist in many aspects of health care, but data on racial/ethnic disparities for neurodegenerative diseases (NDDs), such as dementia and Parkinson's disease (PD), are limited. METHODS: We used North and South Carolina Medicare claims from 2013 to 2017 to evaluate disparities in incidence of NDDs and in health-care utilization and outcomes for patients with NDDs. RESULTS: Disparities in incidence of NDD between Black and White beneficiaries narrowed by 0.37 per 100 person-years from 2014 to 2017. After thorough covariate adjustment, Black beneficiaries had a 4% higher risk of all-cause hospitalization, spent 8% more days in skilled nursing facilities and 14% fewer days in hospice facilities, were 38% less likely to receive physical/occupational therapy services, were 8% less likely to receive dementia medications, and were 19% less likely to receive PD medications than White beneficiaries. DISCUSSION: Effective system-level approaches to promote health equity in NDD diagnosis, treatment, and outcomes are clearly needed. HIGHLIGHTS: Racial disparities in neurodegenerative disease incidence narrowed between 2014 and 2017. Black patients were less likely than White patients to receive hospice services. Black patients were less likely than White patients to receive physical therapy. Black patients were less likely than White patients to receive Alzheimer's disease or Parkinson's disease medications. There is a shortage of neurologists in counties with high dementia incidence.
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Doença de Alzheimer , Equidade em Saúde , Doenças Neurodegenerativas , Doença de Parkinson , Estados Unidos/epidemiologia , Humanos , Idoso , Incidência , Promoção da Saúde , Doença de Parkinson/epidemiologia , Doença de Parkinson/terapia , Medicare , Aceitação pelo Paciente de Cuidados de Saúde , Disparidades em Assistência à SaúdeRESUMO
Systemic lupus erythematosus is a debilitating autoimmune disease in which autoantibodies and autoreactive T cells destroy kidneys and other organs. Disease is clinically and genetically heterogeneous, suggesting that underlying mechanisms vary between patients. We previously used an autoantibody transgenic mouse reporter system to examine the effect of different autoimmune backgrounds on B-cell tolerance, failure of which is a fundamental defect in lupus. We identified a defect consistent with reversible anergy induced by endotoxin stimulation of B cells from Ig transgenic New Zealand Black (NZB) mice. Herein we report that the tolerance defect is revealed by TLR7 and TLR9 as well as TLR4 ligands, with additive effect, and is partially reversed by Mek inhibition. Gene expression analysis reveals significant differences in transcription of multiple TLR pathway genes and ptpn22 in stimulated NZB compared to B6 B cells. Additionally, the defect is detected in Ig transgenic NZB F1 hybrid strains (NZBxNZW)F1 and (B6xNZB)F1. These results implicate an inherited defect wherein NZB anergic B cells maintain coordinated TLR/BCR signaling that permits autoantibody production. Agents targeting these pathways may have therapeutic benefit in the subset of lupus patients that manifest similar defects in B-cell regulation.
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Autoimunidade/genética , Linfócitos B/imunologia , Tolerância Imunológica/genética , Receptores Toll-Like/imunologia , Animais , Autoanticorpos/genética , Autoanticorpos/imunologia , Linfócitos B/metabolismo , Anergia Clonal/genética , Feminino , Genes Dominantes , Humanos , Hibridização Genética , Lúpus Eritematoso Sistêmico/genética , Lúpus Eritematoso Sistêmico/imunologia , Sistema de Sinalização das MAP Quinases , Masculino , Glicoproteínas de Membrana/genética , Glicoproteínas de Membrana/imunologia , Camundongos , Camundongos Endogâmicos NZB , Camundongos Transgênicos , Receptor 4 Toll-Like/genética , Receptor 4 Toll-Like/imunologia , Receptor 7 Toll-Like/genética , Receptor 7 Toll-Like/imunologia , Receptor Toll-Like 9/genética , Receptor Toll-Like 9/imunologia , Receptores Toll-Like/genéticaRESUMO
BACKGROUND: Anti-glomerular basement membrane nephritis and Goodpasture syndrome result from autoantibody (Ab)-mediated destruction of kidney and lung. Ab target the noncollagenous 1 (NC1) domain of alpha3(IV) collagen, but little is known about Ab origins or structure. This ignorance is due in part to the inability to recover monoclonal Ab by transformation of patients' blood cells. The aim of this study was to assess the suitability of two humanized models for this purpose. METHODS: NOD-scid-gamma immunodeficient mice were engrafted either with human CD34+ hematopoietic stem cells (HSC) (Hu-HSC mice) and immunized with alpha3(IV)NC1 collagen containing the Goodpasture epitopes or with nephritis patients' peripheral blood leukocytes (PBL) (Hu-PBL mice). After in vivo immune cell development and/or expansion, recovered human B cells were Epstein Barr virus (EBV)-transformed, screened for antigen (Ag) binding, electrofused with a mouse-human heterohybridoma, subcloned, and human Ab RNA sequenced by PCR after reverse transcription to cDNA. Flow cytometry was used to assess human B cell markers and differentiation in Hu-PBL mice. RESULTS: Sequence analysis of a human Ab derived from an immunized Hu-HSC mouse and reactive with alpha3(IV)NC1 collagen reveals that it is encoded by unmutated heavy and light chain genes. The heavy chain complementarity determining region 3, a major determinant of Ag binding, contains uncommon motifs, including an N-region somatically-introduced highly hydrophobic tetrapeptide and dual cysteines encoded by a uniquely human IGHD2-2 Ab gene segment that lacks a murine counterpart. Comparison of human and mouse autoantibodies suggests that structurally similar murine Ab may arise by convergent selection. In contrast to the Hu-HSC model, transformed human B cells are rarely recovered from Hu-PBL mice, in which human B cells terminally differentiate and lose expression of EBV receptor CD21, thus precluding their transformation and recovery. CONCLUSIONS: Hu-HSC mice reveal that potentially pathogenic B cells bearing unmutated Ig receptors reactive with the NC1 domain on alpha3(IV) collagen can be generated in, and not purged from, the human preimmune repertoire. Uniquely human gene elements are recruited to generate the antigen binding site in at least a subset of these autoantibodies, indicating that humanized models may provide insights inaccessible using conventional mouse models.
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Anticorpos Monoclonais/imunologia , Colágeno Tipo IV/química , Colágeno Tipo IV/imunologia , Sequência de Aminoácidos , Animais , Anticorpos Monoclonais/química , Anticorpos Monoclonais/genética , Linfócitos B/imunologia , Sequência de Bases , Feminino , Células-Tronco Hematopoéticas/metabolismo , Humanos , Leucócitos/metabolismo , Subpopulações de Linfócitos/imunologia , Camundongos , Modelos Animais , Dados de Sequência Molecular , Nefrite/imunologia , Estrutura Terciária de Proteína , Receptores de Complemento 3d/metabolismo , Análise de Sequência de Proteína , Doadores de TecidosRESUMO
INTRODUCTION: The effect of social drivers of health (SDOH) on readmissions and costs after total hip arthroplasty (THA) and total knee arthroplasty (TKA) is poorly understood. Policies such as the Hospital Readmissions Reduction Program have targeted overall readmission reduction, using value-based strategies to improve healthcare quality. However, the implications of SDOH on these outcomes are not yet understood. We hypothesized that the area deprivation index (ADI) as a surrogate for SDOH would markedly influence readmission rates and healthcare costs in the 90-day postprocedural period for THA and TKA. METHODS: We used the 100% US fee-for-service Medicare claims data from 2019 to 2021. Patients were identified using diagnosis-related groups. Our primary outcomes included 90-day unplanned readmission after hospital discharge and cost of care, treated as "high cost" if > 1 standard deviation above the mean. The relationships between ADI and primary outcomes were estimated with logistic regression models. RESULTS: A total of 628,399 patients were included in this study. The mean age of patients was 75.6, 64% were female, and 7.8% were dually eligible for Medicaid. After full covariate adjustment, readmission was higher for patients in more deprived areas (high Area Deprivation Index (ADI)) (low socioeconomic status (SES) group OR: 1.30 [95% confidence intervals 1.23, 1.38]). ADI was associated with high cost before adjustment (low SES group odds ratio 1.08 [95% confidence intervals 1.04, 1.11], P < 0.001), although, after adjustment, this association was lost. DISCUSSION: This analysis highlights the effect of SDOH on readmission rates after THA and TKA. A nuanced understanding of neighborhood-level disparities may facilitate targeted strategies to reduce avoidable readmissions in orthopaedic surgery. Regarding cost, although there is some association between ADI and cost, this study may illustrate that ADI for THA and TKA is not sufficiently granular to identify the contribution of social drivers to elevated costs.
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Several years ago, the US News and World Report changed their risk-adjustment methodology, now relying almost exclusively on chronic conditions for risk adjustment. The impacts of adding selected acute conditions like pneumonia, sepsis, and electrolyte disorders ("augmented") to their current risk models ("base") for 4 specialties-cardiology, neurology, oncology, and pulmonology-on estimates of hospital performance are reported here. In the augmented models, many acute conditions were associated with substantial risks of mortality. Compared to the base models, the discrimination and calibration of the augmented models for all specialties were improved. While estimated hospital performance was highly correlated between the 2 models, the inclusion of acute conditions in risk-adjustment models meaningfully improved the predictive ability of those models and had noticeable effects on hospital performance estimates. Measures or conditions that address disease severity should always be included when risk-adjusting hospitalization outcomes, especially if the goal is provider profiling.
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Cardiologia , Risco Ajustado , Humanos , Hospitais , Hospitalização , Doença AgudaRESUMO
BACKGROUND: Understanding the relationship between neighborhood environment and cardiovascular outcomes is important to achieve health equity and implement effective quality strategies. We conducted a population-based cohort study to determine the association of neighborhood socioeconomic deprivation and 30-day mortality and readmission rate for patients admitted with common cardiovascular conditions. METHODS AND RESULTS: We examined claims data from fee-for-service Medicare beneficiaries aged ≥65 years between 2017 and 2019 admitted for heart failure, valvular heart disease, ischemic heart disease, or cardiac arrhythmias. The primary exposure was the Area Deprivation Index; outcomes were 30-day all-cause death and unplanned readmission. More than 2 million admissions were included. After sequential adjustment for patient characteristics (demographics, dual eligibility, comorbidities), area health care resources (primary care clinicians, specialists, and hospital beds per capita), and admitting hospital characteristics (ownership, size, teaching status), there was a dose-dependent association between neighborhood socioeconomic deprivation and 30-day mortality rate for all conditions. In the fully adjusted model for death, estimated effect sizes of residence in the most disadvantaged versus least disadvantaged neighborhoods ranged from adjusted odds ratio 1.29 (95% CI, 1.22-1.36) for the heart failure group to adjusted odds ratio 1.63 (95% CI, 1.36-1.95) for the valvular heart disease group. Neighborhood deprivation was associated with increased adjusted 30-day readmission rates, with estimated effect sizes from adjusted odds ratio 1.09 (95% CI, 1.05-1.14) for heart failure to adjusted odds ratio 1.19 (95% CI, 1.13-1.26) for arrhythmia. CONCLUSIONS: Neighborhood socioeconomic disadvantage was associated with 30-day mortality rate and readmission for patients admitted with common cardiovascular conditions independent of individual demographics, socioeconomic status, medical risk, care access, or admitting hospital characteristics.
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Doenças Cardiovasculares , Medicare , Readmissão do Paciente , Disparidades Socioeconômicas em Saúde , Idoso , Idoso de 80 Anos ou mais , Feminino , Humanos , Masculino , Doenças Cardiovasculares/mortalidade , Doenças Cardiovasculares/epidemiologia , Doenças Cardiovasculares/terapia , Medicare/estatística & dados numéricos , Características da Vizinhança , Readmissão do Paciente/estatística & dados numéricos , Estudos Retrospectivos , Medição de Risco , Fatores de Risco , Determinantes Sociais da Saúde , Fatores Socioeconômicos , Fatores de Tempo , Estados Unidos/epidemiologiaRESUMO
Members of the galectin family of proteins have been shown to regulate the development and the function of immune cells. We previously identified the increased expression of galectin-1 and galectin-3 mRNA and protein in anergic B cells relative to their naïve counterparts. To investigate the role of these galectins in maintaining B cell tolerance, we crossed mice deficient in galectin-1 or galectin-3 with mice bearing a lupus autoantigen-binding transgenic (Tg) B cell receptor, using a model with a well-characterized B cell tolerance phenotype of deletion, receptor editing and anergy. Here, we present data showing that the global knockout of galectin-1 or galectin-3 yields subtle alterations in B cell fate in autoantibody Tg mice. The absence of galectin-3 leads to a significant increase in the number of Tg spleen B cells, with the recovery of anti-laminin antibodies from a subset of mice. The B cell number increases further in antibody Tg mice with the dual deficiency of both galectin-1 and galectin-3. Isolated galectin-1 deficiency significantly enhances the proliferation of Tg B cells in response to lipopolysaccharide stimulation. These findings add to the growing body of evidence indicating a role for the various galectin family members, and for galectins 1 and 3 in particular, in the regulation of autoimmunity.
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Autoanticorpos/imunologia , Linfócitos B/imunologia , Anergia Clonal/genética , Deleção Clonal/genética , Galectina 1/genética , Galectina 3/genética , Animais , Laminina/imunologia , Camundongos , Camundongos Knockout , TransgenesRESUMO
Rationale: Understanding how systemic forces and environmental exposures impact patient outcomes is critical to advancing health equity and improving population health for patients with pulmonary disease. This relationship has not yet been assessed at the population level nationally. Objectives: To determine whether neighborhood socioeconomic deprivation is independently associated with 30-day mortality and readmission for hospitalized patients with pulmonary conditions, after controlling for demographics, access to healthcare resources, and characteristics of admitting healthcare facilities. Methods: This was a retrospective, population-level cohort study of 100% of United States nationwide Medicare inpatient and outpatient claims from 2016-2019. Patients were admitted for one of four pulmonary conditions (pulmonary infections, chronic lower respiratory disease, pulmonary embolism, and pleural and interstitial lung diseases), defined by diagnosis-related group. The primary exposure was neighborhood socioeconomic deprivation, measured by the area deprivation index. The main outcomes were 30-day mortality and 30-day unplanned readmission, defined by Centers for Medicare and Medicaid Services methodologies. Generalized estimating equations were used to estimate logistic regression models for the primary outcomes, addressing clustering by hospital. A sequential adjustment strategy was first adjusted for age, legal sex, Medicare-Medicaid dual eligibility, and comorbidity burden, then adjusted for metrics of access to healthcare resources, and finally adjusted for characteristics of the admitting healthcare facility. Results: After full adjustment, patients from low socioeconomic status neighborhoods had greater 30-day mortality after admission for pulmonary embolism (odds ratio [OR], 1.26; 95% confidence interval [CI], 1.13-1.40), respiratory infections (OR, 1.20; 95% CI, 1.16-1.25), chronic lower respiratory disease (OR, 1.31; 95% CI, 1.22-1.41), and interstitial lung disease (OR, 1.15; 95% CI, 1.04-1.27) when compared to patients from the highest SES neighborhoods. Low neighborhood socioeconomic status was also associated with 30-day readmission for all groups except the interstitial lung disease group. Conclusions: Neighborhood socioeconomic deprivation may be a key factor driving poor health outcomes for patients with pulmonary diseases.
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Pneumonia , Embolia Pulmonar , Humanos , Idoso , Estados Unidos/epidemiologia , Estudos de Coortes , Estudos Retrospectivos , Medicare , Disparidades Socioeconômicas em Saúde , Hospitalização , Acessibilidade aos Serviços de Saúde , Embolia Pulmonar/epidemiologia , Embolia Pulmonar/terapia , Fatores SocioeconômicosRESUMO
BACKGROUND: Acute care inpatient admissions outside of psychiatric facilities have been increasingly identified as a critical touchpoint for opioid use disorder (OUD) treatment. We sought to describe non-opioid overdose hospitalizations with documented OUD and examine receipt of post-discharge outpatient buprenorphine. METHODS: We examined acute care hospitalizations with an OUD diagnosis in any position within US commercially-insured adults age 18-64 years (IBM MarketScan claims, 2013-2017), excluding opioid overdose diagnoses. We included individuals with ≥ 6 months of continuous enrollment prior to the index hospitalization and ≥ 10 days following discharge. We described demographic and hospitalization characteristics, including outpatient buprenorphine receipt within 10 days of discharge. RESULTS: Most (87%) hospitalizations with documented OUD did not include opioid overdose. Of 56,717 hospitalizations (49,959 individuals), 56.8% had a primary diagnosis other than OUD, 37.0% had documentation of an alcohol-related diagnosis code, and 5.8% end in a self-directed discharge. Where opioid use disorder was not the primary diagnosis, 36.5% were due to other substance use disorders, and 23.1% were due to psychiatric disorders. Of all non-overdose hospitalizations who had prescription medication insurance coverage and who were discharged to an outpatient setting (n = 49, 237), 8.8% filled an outpatient buprenorphine prescription within 10 days of discharge. CONCLUSIONS: Non-overdose OUD hospitalizations often occur with substance use disorders and psychiatric disorders, and very few are followed by timely outpatient buprenorphine. Addressing the OUD treatment gap during hospitalization may include implementing medication for OUD for inpatients with a broad range of diagnoses.
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Buprenorfina , Overdose de Opiáceos , Transtornos Relacionados ao Uso de Opioides , Adulto , Humanos , Adolescente , Adulto Jovem , Pessoa de Meia-Idade , Alta do Paciente , Assistência ao Convalescente , Estudos Retrospectivos , Hospitalização , Transtornos Relacionados ao Uso de Opioides/tratamento farmacológico , Transtornos Relacionados ao Uso de Opioides/epidemiologia , Buprenorfina/uso terapêuticoRESUMO
BACKGROUND AND OBJECTIVES: Patients of low individual socioeconomic status (SES) are at a greater risk of unfavorable health outcomes. However, the association between neighborhood socioeconomic deprivation and health outcomes for patients with neurologic disorders has not been studied at the population level. Our objective was to determine the association between neighborhood socioeconomic deprivation and 30-day mortality and readmission after hospitalization for various neurologic conditions. METHODS: This was a retrospective study of nationwide Medicare claims from 2017 to 2019. We included patients older than 65 years hospitalized for the following broad categories based on diagnosis-related groups (DRGs): multiple sclerosis and cerebellar ataxia (DRG 058-060); stroke (061-072); degenerative nervous system disorders (056-057); epilepsy (100-101); traumatic coma (082-087), and nontraumatic coma (080-081). The exposure of interest was neighborhood SES, measured by the area deprivation index (ADI), which uses socioeconomic indicators, such as educational attainment, unemployment, infrastructure access, and income, to estimate area-level socioeconomic deprivation at the level of census block groups. Patients were grouped into high, middle, and low neighborhood-level SES based on ADI percentiles. Adjustment covariates included age, comorbidity burden, race/ethnicity, individual SES, and sex. RESULTS: After exclusions, 905,784 patients were included in the mortality analysis and 915,993 were included in the readmission analysis. After adjustment for age, sex, race/ethnicity, comorbidity burden, and individual SES, patients from low SES neighborhoods had higher 30-day mortality rates compared with patients from high SES neighborhoods for all disease categories except for multiple sclerosis: magnitudes of the effect ranged from an adjusted odds ratio of 2.46 (95% CI 1.60-3.78) for the nontraumatic coma group to 1.23 (95% CI 1.19-1.28) for the stroke group. After adjustment, no significant differences in readmission rates were observed for any of the groups. DISCUSSION: Neighborhood SES is strongly associated with 30-day mortality for many common neurologic conditions even after accounting for baseline comorbidity burden and individual SES. Strategies to improve health equity should explicitly consider the effect of neighborhood environments on health outcomes.
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Esclerose Múltipla , Acidente Vascular Cerebral , Humanos , Idoso , Estados Unidos , Readmissão do Paciente , Estudos Retrospectivos , Coma , Medicare , Classe Social , Fatores Socioeconômicos , Características de ResidênciaRESUMO
Importance: Beneficiaries dual eligible for Medicare and Medicaid account for a disproportionate share of expenditures due to their complex care needs. Lack of coordination between payment programs creates misaligned incentives, resulting in higher costs, fragmented care, and poor health outcomes. Objective: To inform the design of integrated programs by describing the health care use and spending for need-based subgroups in North Carolina's full benefit, dual-eligible population. Design, Setting, and Participants: This cross-sectional study using Medicare and North Carolina Medicaid 100% claims data (2014-2017) linked at the individual level included Medicare beneficiaries with full North Carolina Medicaid benefits. Data were analyzed between 2021 and 2022. Exposure: Need-based subgroups: community well, home- and community-based services (HCBS) users, nursing home (NH) residents, and intensive behavioral health (BH) users. Measures: Medicare and Medicaid utilization and spending per person-year (PPY). Results: The cohort (n = 333â¯240) comprised subgroups of community well (64.1%, n = 213â¯667), HCBS users (15.0%, n = 50â¯095), BH users (15.2%, n = 50â¯509), and NH residents (7.5%, n = 24â¯927). Overall, 61.1% reported female sex. The most common racial identities included Asian (1.8%), Black (36.1%), and White (58.7%). Combined spending for Medicare and Medicaid was $26â¯874 PPY, and the funding of care was split evenly between Medicare and Medicaid. Among need-based subgroups, combined spending was lowest among community well at $19â¯734 PPY with the lowest portion (38.5%) of spending contributed by Medicaid ($7605). Among NH residents, overall spending ($68â¯359) was highest, and the highest portion of spending contributed by Medicaid (70.1%). Key components of spending among HCBS users' combined total of $40â¯069 PPY were clinician services on carrier claims ($14â¯523) and outpatient facility services ($9012). Conclusions and relevance: Federal and state policy makers and administrators are developing strategies to integrate Medicare- and Medicaid-funded health care services to provide better care to the people enrolled in both programs. Substantial use of both Medicare- and Medicaid-funded services was found across all need-based subgroups, and the services contributing a high proportion of the total spending differed across subgroups. The diversity of health care use suggests a tailored approach to integration strategies with comprehensive set benefits that comprises Medicare and Medicaid services, including long-term services and supports, BH, palliative care, and social services.
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Medicaid , Medicare , Humanos , Feminino , Idoso , Estados Unidos , Estudos Transversais , Gastos em Saúde , North CarolinaRESUMO
BACKGROUND: Despite recommendations for molecular testing irrespective of patient characteristics, differences exist in receipt of molecular testing for oncogenic drivers amongst metastatic non-small cell lung cancer (mNSCLC) patients. Exploration into these differences and their effects on treatment is needed to identify opportunities for improvement. PATIENTS AND METHODS: We conducted a retrospective cohort study of adult patients diagnosed with mNSCLC between 2011 and 2018 using PCORnet's Rapid Cycle Research Project dataset (n = 3600). Log-binomial, Cox proportional hazards (PH), and time-varying Cox regression models were used to ascertain whether molecular testing was received, and time from diagnosis to molecular testing and/or initial systemic treatment in the context of patient age, sex, race/ethnicity, and multiple comorbidities status. RESULTS: The majority of patients in this cohort were ≤ 65 years of age (median [25th, 75th]: 64 [57, 71]), male (54.3%), non-Hispanic white individuals (81.6%), with > 2 comorbidities in addition to mNSCLC (54.1%). About half the cohort received molecular testing (49.9%). Patients who received molecular testing had a 59% higher probability of initial systemic treatment than patients who were yet to receive testing. Multiple comorbidity status was positively associated with receipt of molecular testing (RR, 1.27; 95% CI 1.08, 1.49). CONCLUSION: Receipt of molecular testing in academic centers was associated with earlier initiation of systemic treatment. This finding underscores the need to increase molecular testing rates amongst mNSCLC patients during a clinically relevant period. Further studies to validate these findings in community centers are warranted.
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Carcinoma Pulmonar de Células não Pequenas , Neoplasias Pulmonares , Adulto , Humanos , Masculino , Carcinoma Pulmonar de Células não Pequenas/diagnóstico , Carcinoma Pulmonar de Células não Pequenas/tratamento farmacológico , Carcinoma Pulmonar de Células não Pequenas/genética , Neoplasias Pulmonares/diagnóstico , Neoplasias Pulmonares/tratamento farmacológico , Neoplasias Pulmonares/genética , Estudos Retrospectivos , Etnicidade , Técnicas de Diagnóstico MolecularRESUMO
Objectives: To ascertain common experiences and needs of a diverse group of caregivers challenged by hurricanes/floods and COVID-19. Methods: In-depth interviews with unpaid caregivers in U.S. Southeast/Gulf Coast states who had experienced caregiving during a natural disaster and during COVID-19. Results: Caregivers report challenges including daily living disruption, altered social supports, complicated health management, additional disaster planning, and emotional/financial impacts. Caregivers suggested helpful resources, policy options, and preparatory tools at individual, local, and health system levels to mediate discontinuity. Conclusions: Our data describe combined caregiver experiences of hurricanes/floods and the pandemic. Caregivers experience unique burdens related to care recipient diagnosis, location, and veteran status. Access to community supports varies as they manage the tasks required for care recipients' health and safety. Our findings indicate the need for public health reinforcement of caregiving though caregiver pre-planning and targeted support. Bolstering understanding of communities' caregiving capacity though first responder trainings and caregiver registries may enhance health and safety.
RESUMO
Critically needed programs designed to support family caregivers have shown inconsistent reductions in stress and burden. To explore drivers of improvement in caregiver outcomes after participation in a support intervention we analyzed data from a one-on-one, tailored problem-solving intervention targeting caregiver wellbeing (2015-2019, n = 503). We explored data patterns across 21 individual, household, and program-level variables using elastic net regression to identify drivers of improvements, and their relative importance. Baseline subjective burden, baseline depressive symptom scores, baseline caregiver problem solving, African American race, and site and coach fixed effects were the most consistent drivers of changes across the explored caregiver outcomes. Caregiver and program characteristics may be promising avenues to target to decrease distress and burden during intervention design. Interventions focusing on highly distressed caregivers may lead to greater improvements. More research is needed to identify how site or interventionists characteristics drive positive intervention effects.
Assuntos
Cuidadores , Resolução de Problemas , HumanosRESUMO
Patients and rodents with Goodpasture's syndrome (GPS) develop severe autoimmune crescentic glomerulonephritis, kidney failure, and lung hemorrhage due to binding of pathogenic autoantibodies to the NC1 domain of the alpha3 chain of type IV collagen. Target epitopes are cryptic, normally hidden from circulating Abs by protein-protein interactions and the highly tissue-restricted expression of the alpha3(IV) collagen chain. Based on this limited Ag exposure, it has been suggested that target epitopes are not available as B cell tolerogens. To determine how pathogenic anti-GPS autoantibody responses are regulated, we generated an Ig transgenic (Tg) mouse model that expresses an Ig that binds alpha3(IV)NC1 collagen epitopes recognized by serum IgG of patients with GPS. Phenotypic analysis reveals B cell depletion and L chain editing in Tg mice. To determine the default tolerance phenotype in the absence of receptor editing and endogenous lymphocyte populations, we crossed Tg mice two generations with mice deficient in Rag. Resulting Tg Rag-deficient mice have central B cell deletion. Thus, development of Tg anti-alpha3(IV)NC1 collagen B cells is halted in the bone marrow, at which point the cells are deleted unless rescued by a Rag enzyme-dependent process, such as editing. The central tolerance phenotype implies that tolerizing self-Ag is expressed in bone marrow.