Survival and recovery modeling of acute kidney injury in critically ill adults.

Objectives: Acute kidney injury is common among the critically ill. However, the incidence, medication use, and outcomes of acute kidney injury have been variably described. We conducted a single-center, retrospective cohort study to examine the risk factors and correlates associated with acute kidney injury in critically ill adults with a particular focus on medication class usage. Methods: We reviewed the electronic medical records of all adult patients admitted to an intensive care unit between 1 February and 30 August 2020. Acute kidney injury was defined by the 2012 Kidney Disease: Improving Global Outcomes guidelines. Data included were demographics, comorbidities, symptoms, laboratory parameters, interventions, and outcomes. The primary outcome was acute kidney injury incidence. A Least Absolute Shrinkage and Selection Operator regression model was used to determine risk factors associated with acute kidney injury. Secondary outcomes including acute kidney injury recovery and intensive care unit mortality were analyzed using a Cox regression model. Results: Among 226 admitted patients, 108 (47.8%) experienced acute kidney injury. 37 (34.3%), 39 (36.1%), and 32 patients (29.6%) were classified as acute kidney injury stages I-III, respectively. Among the recovery and mortality cohorts, analgesics/sedatives, anti-infectives, and intravenous fluids were significant (p-value < 0.05). The medication classes IV-fluid electrolytes nutrition (96.7%), gastrointestinal (90.2%), and anti-infectives (81.5%) were associated with an increased odds of developing acute kidney injury, odd ratios: 1.27, 1.71, and 1.70, respectively. Cox regression analyses revealed a significantly increased time-varying mortality risk for acute kidney injury-stage III, hazard ratio: 4.72 (95% confidence interval: 1-22.33). In the recovery cohort, time to acute kidney injury recovery was significantly faster in stage I, hazard ratio: 9.14 (95% confidence interval: 2.14-39.06) cohort when compared to the stage III cohort. Conclusion: Evaluation of vital signs, laboratory, and medication use data may be useful to determine acute kidney injury risk stratification. The influence of particular medication classes further impacts the risk of developing acute kidney injury, necessitating the importance of examining pharmacotherapeutic regimens for early recognition of renal impairment and prevention.

Initial maintenance therapy adherence among older adults with asthma-COPD overlap.

OBJECTIVES: To examine the impact of initial maintenance therapy (IMT) type (inhaled corticosteroid [ICS] vs fixed-dose combination of ICS and long-acting ß agonist [ICS/LABA]) on trajectories of adherence among older adults (≥ 65 years) with coexisting asthma and chronic obstructive pulmonary disease (COPD), known as asthma-COPD overlap (ACO). STUDY DESIGN: We used a longitudinal, retrospective cohort design. METHODS: This study used a cohort of older adults with ACO using longitudinal data from a 10% sample of Optum's Deidentified Clinformatics Data Mart. We adopted group-based trajectory modeling to identify medication adherence trajectories over 12 months. Multinomial logistic regressions were used to evaluate the unadjusted and adjusted associations of IMT medication and adherence trajectory categories. All analyses accounted for treatment option selection bias with inverse probability treatment weighting. RESULTS: Of 1555 individuals, 73% of the sample used ICS/LABA for IMT. Four medication adherence trajectories were observed regardless of regimen: (1) persistent high adherence (12.0%), (2) progression to high adherence (20.8%), (3) progression to low adherence (10.5%), and (4) persistent low adherence (56.7%). Those who were initiated on ICS/LABA were less likely to have persistent low adherence (unadjusted odds ratio [OR], 0.44; 95% CI, 0.29-0.67) compared with those initiated on ICS monotherapy when "persistent high adherence" was used as the reference group. The relationship remained significant in adjusted regressions (adjusted OR, 0.38; 95% CI, 0.24-0.59). CONCLUSIONS: Real-world evidence suggests that using ICS/LABA for IMT may decrease the likelihood of persistent low adherence over time among older adults with ACO compared with ICS monotherapy.

Economic Burden of Treatment-Resistant Depression among Adults with Chronic Non-Cancer Pain Conditions and Major Depressive Disorder in the US.

OBJECTIVE: Major depressive disorder (MDD) and chronic non-cancer pain conditions (CNPC) often co-occur and exacerbate one another. Treatment-resistant depression (TRD) in adults with CNPC can amplify the economic burden. This study examined the impact of TRD on direct total and MDD-related healthcare resource utilization (HRU) and costs among commercially insured patients with CNPC and MDD in the US. METHODS: The retrospective longitudinal cohort study employed a claims-based algorithm to identify adults with TRD from a US claims database (January 2007 to June 2017). Costs (2018 US$) and HRU were compared between patients with and without TRD over a 12-month period after TRD/non-TRD index date. Counterfactual recycled predictions from generalized linear models were used to examine associations between TRD and annual HRU and costs. Post-regression linear decomposition identified differences in patient-level factors between TRD and non-TRD groups that contributed to the excess economic burden of TRD. RESULTS: Of the 21,180 adults with CNPC and MDD, 10.1% were identified as having TRD. TRD patients had significantly higher HRU, translating into higher average total costs (US$21,015TRD vs US$14,712No TRD) and MDD-related costs (US$1201TRD vs US$471No TRD) compared with non-TRD patients (all p < 0.001). Prescription drug costs accounted for 37.6% and inpatient services for 30.7% of the excess total healthcare costs among TRD patients. TRD patients had a significantly higher number of inpatient (incidence rate ratio [IRR] 1.30, 95% CI 1.14-1.47) and emergency room visits (IRR 1.21, 95% CI 1.10-1.34) than non-TRD patients. Overall, 46% of the excess total costs were explained by differences in patient-level characteristics such as polypharmacy, number of CNPC, anxiety, sleep, and substance use disorders between the TRD and non-TRD groups. CONCLUSION: TRD poses a substantial direct economic burden for adults with CNPC and MDD. Excess healthcare costs may potentially be reduced by providing timely interventions for several modifiable risk factors.

The impact of telemental health use on healthcare costs among commercially insured adults with mental health conditions.

OBJECTIVE: To determine the impact of telemental health (TMH) use on total healthcare costs and mental health (MH)-related costs paid by a third party among adults with mental health conditions (MHC). METHOD: This study employed a pre-post design with a non-equivalent control group. The cohort comprised adults with MHCs identified using diagnosis codes from de-identified claims data of the Optum Clinformatics DataMart (2010 January 01 to 2017 June 30). We identified mental health (MH) service users and TMH users (N = 348) based on procedure codes. Non-users (N = 238,595) were defined as those who only used in-person MH services. A Difference-in-Differences (DID) analysis was performed within a multivariable two-part model (TPM) framework to examine the impact of TMH use on adjusted standardized costs (2018 US $) of all healthcare services and MH services. Patient-level and state-level factors were adjusted in TPM. RESULTS: TMH use was associated with significantly higher MH-related costs [Marginal effect = $461.3, 95% confidence interval: $142.4-$780.2] and an excess of $370 increase in MH-related costs at follow-up as compared to baseline. However, TMH use was not associated with an increase in total third-party healthcare costs nor with changes in total costs from baseline to follow-up. CONCLUSIONS: Despite having a higher likelihood of MH services use and MH-related costs, TMH users did not have higher total costs as compared to adults using only in-person MH services. Our findings suggest that TMH can increase access to MH care without increasing total healthcare costs among adults with MHC. Future studies exploring whether TMH use can lead to cost-savings over a longer period are warranted.

Associations of multimorbidity and patient-reported experiences of care with conservative management among elderly patients with localized prostate cancer.

BACKGROUND: Many elderly localized prostate cancer patients could benefit from conservative management (CM). This retrospective cohort study examined the associations of patient-reported access to care and multimorbidity on CM use patterns among Medicare Fee-for-Service (FFS) beneficiaries with localized prostate cancer. METHODS: We used linked Surveillance, Epidemiology, and End Results cancer Registry, Medicare Claims, and the Medicare Consumer Assessment of Healthcare Providers and Systems (MCAHPS) survey files. We identified FFS Medicare Beneficiaries (age ≥ 66; continuous enrollment in Parts A & B) with incident localized prostate cancer from 2003 to 2013 and a completed MCAHPS survey measuring patient-reported experiences of care within 24 months after diagnosis (n = 496). We used multivariable models to examine MCAHPS measures (getting needed care, timeliness of care, and doctor communication) and multimorbidity on CM use. RESULTS: Localized prostate cancer patients with multimorbidity were less likely to use CM (adjusted odds ratio (AOR)=0.42 (0.27- 0.66), P < .001); those with higher scores on timeliness of care (AOR = 1.21 (1.09, 1.35), P < .001), higher education attainment (3.21 = AOR (1.50,6.89), P = .003), and impaired mental health status (4.32 = AOR (1.86, 10.1) P < .001) were more likely to use CM. CONCLUSION(S): Patient-reported experience with timely care was significantly and positively associated with CM use. Multimorbidity was significantly and inversely associated with CM use. Addressing specific modifiable barriers to timely care along the cancer continuum for elderly localized prostate cancer patients with limited life expectancy could reduce the adverse effects of overtreatment on health outcomes and costs.

Disparities in the Initial Local Treatment of Older Women with Early-Stage Breast Cancer: A Population-Based Study.

BACKGROUND: Although breast cancer is most prevalent among older women, the majority are diagnosed at an early stage. When diagnosed at an early stage, women have the option of breast-conserving surgery (BCS) plus radiation therapy (RT) or mastectomy for the treatment of early-stage breast cancer (ESBC). Omission of RT when receiving BCS increases the risk for recurrence and poor survival. Yet, a small subset of older women may omit RT after BCS. This study examines the current patterns of local treatment for ESBC among older women. METHODS: This study conducted a retrospective observational analysis using the Surveillance, Epidemiology, and End Results (SEER)-Medicare linked dataset of women age ≥66 diagnosed with stage I-II breast cancer in 2003-2009. SEER-Medicare data was additionally linked with data from the Area Resource File (ARF) to examine the association between area-level healthcare resources and treatment. Two logistic regression models were used to estimate how study factors were associated with receiving (1) BCS versus BCS+RT and (2) Mastectomy versus BCS+RT. A stratified analysis was also conducted among women aged <70 years. RESULTS: Among 45,924 patients, 55% received BCS+RT, 23% received mastectomy, and 22% received BCS only. Women of increasing age, comorbidity, primary care provider visits, stage II disease, and nonwhite race were more likely to have mastectomy or BCS only, than BCS+RT. Women diagnosed in 2004-2006, treated by an oncology surgeon, residing in metro areas, areas of greater education and income, were less likely to receive mastectomy or BCS only, than BCS+RT. While women aged <70 years were more likely to receive BCS+RT, socioeconomic and physician specialties were associated with receiving BCS only. CONCLUSIONS: Over half of older women with ESBC initially receive BCS+RT. The likelihood for mastectomy and BCS only increases with age, comorbidity, and vulnerable socio-demographic characteristics. Findings demonstrate continued treatment disparities among certain vulnerable populations.

Health behaviors among breast, prostate, and colorectal cancer survivors: a US population-based case-control study, with comparisons by cancer type and gender.

PURPOSE: The aim of this study is to compare health behaviors between breast, prostate, female, and male colorectal cancer survivors to noncancer controls, stratified by short- and long-term survivors, and between cancer types and genders. METHODS: A 3:1 population-based sample of breast (6,259), prostate (3,609), female colorectal (1,082), and male colorectal (816) cancer survivors from the 2009 Behavioral Risk Factor Surveillance System survey were matched to noncancer controls on age, gender, race/ethnicity, income, insurance, and region of the US. The likelihood of flu immunization, physical check-up, cholesterol check, body mass index (BMI), physical activity, diet (5-A-Day), smoking, and alcohol use were compared between groups using binomial logistic regression models. RESULTS: Short-term breast cancer survivors were significantly more likely to meet multiple behavioral recommendations, than controls, but the likelihood decreased in the long term. Breast and female colorectal cancer survivors were up to 2.27 (95 % CI 1.90, 2.71) and 1.89 times more likely (95 % CI 1.60, 2.24) to meet the 5-A-Day and BMI recommendations, up to 0.54 times less likely (95 % CI 0.46, 0.64) to drink any alcohol, but were 0.68 times less likely (95 % CI 0.49, 0.95) to meet the physical activity recommendation, compared to prostate and male colorectal cancer survivors. CONCLUSIONS: Some cancer survivors may engage in better health behaviors shortly after diagnosis, but the majority of cancer survivors do not have better health behaviors than individuals without a history of cancer. However, a consistent pattern of behavioral differences exist between male and female cancer survivors. IMPLICATIONS FOR CANCER SURVIVORS: Gender differences in health behaviors among cancer survivors may be influenced by perceptions of masculinity/femininity and disease risk. Ongoing health behavioral promotion and disease prevention efforts could be improved by addressing these perceptions.