Adapting a clinical comorbidity index for use with ICD-9-CM administrative databases

In-hospital mortality of high-risk pulmonary embolism: a nationwide population-based cohort study in Portugal from 2010 to 2018

BACKGROUND

The mortality associated with high-risk pulmonary embolism (PE) is remarkably high, and reperfusion to unload right ventricle should be a priority. However, several registries report reperfusion underuse. In Portugal, epidemiological data about the incidence, rate of reperfusion and mortality of high-risk PE are not known.

METHODS

Nationwide population-based temporal trend study in the incidence and outcome of high-risk PE, who were admitted to hospitals of the National Health Service in Portugal between 2010 and 2018. High-risk PE was defined as patients with PE who developed cardiogenic shock or cardiac arrest. International Classification of Diseases (ICD), 9th and 10th revision, Clinical Modification codes, were used for data from the period between 2010 and 2016 (ICD-9-CM) and 2017-2018 (ICD-10-CM), respectively. The assessment focused on trends in the use of reperfusion treatment, which was defined by application of thrombolysis or pulmonary embolectomy. A comparison was made between the use or non-use of reperfusion therapy in order to examine trends in in-hospital mortality among high-risk PE cases.

RESULTS

From 2010 and 2018, there were 40.311 hospitalization episodes for PE in adult patients at hospitals of the National Health Service in mainland Portugal. There was a significant increase in the annual incidence of PE (41/100.000 inhabitants in 2010 to 46/100.000 in 2018; R2=0.582, p = 0.010). The average annual incidence was 45/100.000 inhabitants/year, with 2,7% of the PE episodes (1104) categorized as high-risk. The mortality rate associated with high-risk PE was high, although it has decreased over the years (74.2% in 2010 to 63.6% in 2018; R2=0.484; p = 0.022). Thrombolytic therapy was underused in high-risk PE, and its usage has not increased in recent years (17.3% in 2010 to 21.1% in 2018, R2=-0.127; p = 0.763). Surgical pulmonary embolectomy was used in 0.27% of cases, and there was no registry of catheter-directed thrombolysis. Patients with high-risk PE undergoing reperfusion therapy had lower in-hospital mortality compared to non-reperfused patients (OR=0.52; IC95% 0.38-0.70).

CONCLUSION

In Portugal, between 2010 and 2018, very few patients with PE developed high-risk forms of the disease, but the mortality rate among those patients was high. The low reperfusion rate could be associated with high in-hospital mortality and highlights the need to implement advanced therapies, as an alternative to systemic thrombolysis.

Long-term public healthcare burden associated with intimate partner violence among Canadian women: A cohort study

Intimate partner violence (IPV) is a major global health issue, yet few studies explore its long-term public healthcare burden in countries with universal healthcare systems. This study analyzes this burden among Canadian women using data from the Neighborhood Effects on Health and Wellbeing survey and Ontario Health Insurance Plan (OHIP) records from 2009 to 2020. We employed inverse probability weighting with regression adjustment to estimate differences in cumulative costs and OHIP billings between those reporting exposure to IPV during the survey and those who did not. Our sample included 1,094 women, with 38.12 % reporting IPV exposure via the Hurt, Insult, Threaten, Scream scale. Findings show a significant public healthcare burden due to IPV: women reporting IPV in 2009 had an average of 17 % higher healthcare costs and 41 additional OHIP billings (0.1732;95 % CI: 0.0578-0.2886; 41.23;95 % CI: 12.63-69.82). Policies prioritizing primary prevention and integration of trauma-informed care among healthcare providers are vital to alleviate the long-term burden on public health systems.

Outcomes and Complications After Elective Thoracic and Lumbar Spinal Fusion in Elderly Patients: A Comparison of Methods to Predict Adverse Events

Study DesignRetrospective study.ObjectivesThe current study compares the ability of the modified Frailty Index (mFI), the American Society of Anesthesiologists (ASA) classification, the modified Charleston Comorbidity Index (mCCI), the American College of Surgeons Surgical Risk Calculator (SRC), and the Fusion Risk Score (FRS) to predict perioperative outcomes.MethodsComorbidity indices were calculated for patients undergoing elective thoracic and lumbar spinal fusion at a single institution and assessed for their discriminative ability in predicting the desired outcomes using an area under the curve (AUC) analysis.Results393 patients met the inclusion and exclusion criteria. Patients being treated for adult spinal deformity (ASD) had the highest rate of complications (44.4%). The FRS had acceptable discrimination (AUC >0.7) and the highest ability among the methods studied to predict any adverse effects, new neurological deficit, return to OR within 90 days, and surgical site infection. It had good discrimination ability (AUC >0.8) predicting durotomy, respiratory failure (RF) requiring intubation, hemodynamic instability, and sepsis. The SRC had acceptable discrimination and highest ability to predict deep venous thrombosis (DVT). The mCCI had excellent and the highest ability to predict acute renal failure (ARF). For the other outcomes, the indices had either poor predictive ability (AUC 0.6-0.7) or no discriminative ability (AUC <0.6).ConclusionsThe FRS had a better ability than the ASA, mCCI, mFI, and SRC to predict the most perioperative adverse events and reoperation. Further study is needed to develop preoperative indices with better predictive ability of postoperative outcomes.

Peri-Procedural Outcomes of Left Atrial Appendage Occlusion in Lower Versus Higher CHA2DS2-VASc Score

Percutaneous left atrial appendage occlusion (LAAO) is used to prevent stroke in atrial fibrillation. We present a national registry analysis of peri‑procedural outcomes of LAAO among patients with lower versus higher CHA2DS2-VASc score. The National Readmissions Database was used to perform a retrospective review of all hospitalizations for percutaneous endocardial LAAO identified between September 2015 and November 2019. ICD codes for congestive heart failure, hypertension, type 2 diabetes, stroke, transient ischemic attack, thromboembolism, and vascular disease were identified. CHA2DS2-VASc was calculated. Lower CHA2DS2-VASc score was defined as <5 and higher score as ≥5. Propensity matched (PSM) analysis at index hospitalization and 30 days was used to compare a matched sample of patients undergoing LAAO with lower and higher CHA2DS2-VASc. Outcomes examined included all-cause mortality, stroke, major bleeding, pericardial effusion, and cardiac tamponade. A sample of patients who underwent LAAO with lower CHA2DS2-VASc (n = 40,879) and higher CHA2DS2-VASc (n = 14,438) was identified for crude analysis. From this cohort, a sample of patients with lower CHA2DS2-VASc (n = 14,219) and higher CHA2DS2-VASc (n = 14,388) was selected for PSM analysis. Both crude and PSM analyses at index hospitalization found higher odds of mortality in the higher CHA2DS2-VASc group but no significant difference in odds of major bleeding, stroke, pericardial effusion, or cardiac tamponade. Our findings showed associated a higher CHA2DS2-VASc score with a higher risk of mortality without an increased risk of common complications peri‑procedurally. In conclusion, findings display the overall safety of LAAO for patients with both lower and higher CHA2DS2-VASc score.

How Is Preoperative Opioid Use Associated With Readmissions and Outcomes in Lower Extremity Trauma?

BACKGROUND

Opioid use disorder (OUD) has been implicated as a potential risk factor for adverse outcomes and readmissions in various surgical procedures. Patients admitted with an open fracture of the lower extremity often have multifarious pain needs, require surgical procedures, and have prolonged rehabilitation; previous OUD complicates this process. Our goal was to describe at a national level how OUD is associated with readmission, complications, and healthcare expenditure for patients admitted with open lower extremity fractures.

QUESTIONS/PURPOSES

(1) Do patients with OUD who were treated for open lower extremity fractures have higher odds of readmission compared with patients without OUD? (2) Do patients with OUD who were treated for open lower extremity fractures have higher healthcare utilization (specifically, length of stay and hospitalization charges and costs)?

METHODS

This was a retrospective, comparative study using the Nationwide Readmissions Database, which is the largest nationally representative readmissions database in the United States. Patients were included if they had an ICD-10-CM principal diagnosis of open lower extremity fracture. Between January 1, 2019, and September 30, 2019, a total of 17,811 patients were admitted for open lower extremity fractures and entered in the National Readmissions Database. Of the 17,811 patients, 2.3% (410) had a secondary diagnosis of OUD and 97.7% (17,401) did not. The mean age was 46 years for both groups. The most common operative procedure was debridement, and 1.5% of patients received a flap for reconstruction. Opioid disorders were identified using ICD-10-CM codes. Ninety-day complications and readmissions were characterized for the calendar year. Patients undergoing flap-based reconstructions were identified with ICD-10-PR codes. Confounders (patient demographic and hospital characteristics) were adjusted for using multivariable regression analysis models.

RESULTS

After controlling for potentially confounding variables such as primary payer, Charlson comorbidity index, Gustillo type, and bone density, we found that patients with OUD had greater odds of readmission after open lower extremity fractures (adjusted OR 1.45 [95% confidence interval (CI) 1.0 to 2.0]; p = 0.03). The 90-day infection occurrence was higher in patients with OUD (adjusted OR 1.96 [95% CI 1.0 to 3.8]; p = 0.049) and was the primary reason for readmission in both groups. Moreover, 11% (11 of 103) of patients with OUD were readmitted with opioid-induced complications, which was exclusively observed in this cohort. Patients with OUD also had longer hospital stays (adjusted mean difference 2.2 days [95% CI 0.5 to 3.8]; p = 0.01) and higher hospitalization charges (adjusted mean difference in USD 34,000 [95% CI 1000 to 66,000]; p = 0.04) and costs (adjusted mean difference in USD 7000 [95% CI 2000 to 13,000]; p = 0.007) than those without OUD.

CONCLUSION

These findings suggest that mitigating infection and opioid overdose, addiction, and constipation in patients with OUD could reduce readmissions in lower extremity fracture patients. Future research should focus on antibiotic and wound care compliance and the early and frequent engagement of postoperative opioid addiction support services.

LEVEL OF EVIDENCE

Level III, therapeutic study.

Clinical significance of anti-Ro and Anti-La antibodies: The role of isolated anti-La

ObjectivesThe aim of the present study was to describe demographic, clinical, and immunological characteristics of SLE patients with anti-La/SSB antibodies positive versus anti-La/SSB negative patients.MethodsRetrospective cross-sectional study, including all patients with SLE (≥4 ACR-1997 criteria) recruited in RELESSER registry. Sociodemographic, clinical, serological and comorbidities variables were collected. Anti-Ro-/La + patients were compared with the rest of the patients.ResultsIn a study involving 4219 systemic lupus erythematosus (SLE) patients, 44/3893 (1.1%) were found to be positive for isolated anti-La/SSB antibodies. The mean age was 33.77 years, with a majority being female (88.6%) and Caucasian (90.5%). The most frequent comorbidities were smoking (48.8%), dyslipidemia (47.7%), and arterial hypertension (31.8%). Photosensitivity and mucosal ulcers were more common in anti-Ro+/La + patients compared to anti-Ro+/La- and anti-Ro-/La- patients. Anti-Ro+/La + patients had a lower frequency of lupus nephritis compared to anti-Ro+/La- patients. A multivariable regression model, considering various confounding factors, was applied to compare anti-La/SSB positive patients with negative ones. Isolated anti-La/SSB positive patients showed a lower occurrence of lupus nephritis and a higher frequency of cardiac manifestations.ConclusionsThe study suggests that patients with isolated anti-La/SSB antibodies may have a unique clinical profile, with a potential protective effect against lupus nephritis but an increased likelihood of cardiac manifestations.

Fracture risk by cortisol excess status in patients with adrenal incidentalomas: a population-based cohort study

Adrenal incidentalomas (AIs) may secrete excess cortisol, representing an elevated endogenous exposure to glucocorticoids, which could decrease bone mineral density and increase fracture risk. However, measurement of cortisol excess is not routinely done in patients with AI; thus, those with hormonally active AI at increased risk for fracture are under-identified. We sought to examine the association between excess cortisol levels and the incidence of fragility fracture in people with AI. This retrospective cohort study, conducted within two Kaiser Permanente regions (Southern California and Georgia), comprised women and men aged ≥50 yr with identified AI in the study period January 1, 2015-August 31, 2022. Patients' cortisol excess status was categorized by the type of test conducted (if any) and the test result. Fractures and relevant covariates were ascertained via International Classification of Diseases (ICD)-9/10 codes. Hazard ratios (HR) were estimated using Cox proportional hazard models with mortality as a competing risk. Among the cohort of 14 886 patients with AI, 273 (1.8%) had autonomous cortisol secretion (ACS) confirmed by dexamethasone suppression test (DST) results >1.8 μg/dL (>50 nmol/L), and another 201 (1.4%), tested with urine free or random cortisol tests, had results suggestive of excess cortisol production. Most of the cohort (n = 9353, 62.8%) were untested around AI diagnosis or during follow-up. Compared to patients with normal DST results (and adjusted for age, sex, race/ethnicity, and several other clinical characteristics), the estimated HR of fracture risk for patients with ACS (HR 1.42, CI 0.86-2.32), evidence of cortisol excess (1.41, 0.85-2.32), and untested patients (1.28, 0.88-1.87) were suggestive of elevated risk. However, none of the elevated hazard rates were statistically significant at the 95% significance level. The apparent elevated risk in the untested patients suggests that many untested patients may have hormonally active AI that puts them at risk for fracture from secondary osteoporosis.

Association of prostate-specific antigen density with prostate cancer mortality after a benign systematic prostate biopsy result

OBJECTIVE

To assess the association between prostate-specific antigen (PSA) density (PSAD) and prostate cancer mortality after a benign result on systematic transrectal ultrasonography (TRUS)-guided prostate biopsy.

PATIENTS AND METHODS

This retrospective study used data from the Finnish Randomised Study of Screening for Prostate Cancer (FinRSPC) collected between 1996 and 2020. We identified men aged 55-71 years randomised to the screening arm with PSA ≥4.0 ng/mL and a benign systematic TRUS-guided biopsy result. The cumulative prostate cancer mortality of men stratified by a PSAD cutoff of 0.15 ng/mL/cm3 was modelled with competing risk functions. The ability of PSAD, PSA, and base variables (age at biopsy, DRE result, socioeconomic status, 5α-reductase inhibitor usage, family history, and Charlson Comorbidity Index (CCI)) to predict prostate cancer death was compared using c-statistics and a likelihood ratio test.

RESULTS

After excluding 10 men without PSA data within 2 years of the biopsy and 65 without prostate volume data, 2276 men were eligible for inclusion in the study. A total of 50 men died from prostate cancer and 1028 from other causes during a median (interquartile range) follow-up of 17.4 (13.2-20.9) years. The cumulative prostate cancer mortality of men with PSAD <0.15 ng/mL/cm3 was significantly lower than that of men with PSAD ≥0.15 ng/mL/cm3: 0.5% (95% confidence interval [CI] 0.2%-1.1%) vs 2.0% (95% CI 1.2%-3.1%) at 15 years (Grey's test, P = 0.001). The model consisting of PSAD, PSA and the base variables predicted prostate cancer mortality (c-statistic 0.781) significantly better than either the base variables alone (c-statistic 0.737; likelihood-ratio test, P = 0.003) or the base variables and PSA (c-statistic 0.765; likelihood-ratio test, P = 0.039).

CONCLUSION

Prostate cancer mortality after a benign systematic TRUS-guided biopsy is low. In these patients, PSAD predicts prostate cancer mortality and provides additional value to other clinical variables. PSAD-based stratification can be used to guide follow-up strategy.

Impact of peripheral nerve blocks on chronic opioid use after elective total knee arthroplasty in the United States

BACKGROUND

Peripheral nerve blocks (PNBs), either single-shot injection or continuous catheter infusion, are increasingly used in total knee arthroplasties (TKAs). Although recent data show equivalence between both modalities in immediate perioperative analgesia, comparative data on longer-term outcomes such as chronic opioid use are scarce.

METHODS

Using US Merative MarketScan commercial claims data (2018-22; n=126 860 TKAs), we compared: (1) patients receiving PNB vs those who did not; and (2) single-shot vs continuous catheter infusion PNB. Primary outcomes were: (1) 'chronic opioid dependence' (>120 pills of opioids prescribed or >10 prescriptions between postoperative day 90 and 180); and (2) 'chronic opioid use' (any opioid refill between postoperative day 90 and 180). Multivariable models measured associations between PNB modalities and outcomes.

RESULTS

Incidence of 'chronic opioid dependence' was 0.7%, 0.8%, and 0.9% among patients without PNB, with single-shot PNB, and with continuous PNB, respectively. For 'chronic opioid use', this was 12.6%, 13.8%, and 14.3%. Multivariable analyses indicated no association between PNB (yes/no and modality) utilisation and 'chronic opioid dependence'. However, single-shot (OR 1.01, 95% CI 1.01-1.02; P<0.001) and continuous PNB (OR 1.01, 95% CI 1.01-1.02; P<0.001) compared with no PNB use were associated with slightly higher odds of 'chronic opioid use'.

DISCUSSION

Our results did not show any clinically meaningful differences in postoperative chronic opioid use or dependence across patients receiving single-shot PNB or continuous PNB treatment. Future prospective registry data might be indicated to further address this question.

Comparative Effectiveness of Glucagon-Like Peptide-1 Receptor Agonists and Sodium/Glucose Cotransporter 2 Inhibitors in Preventing Chronic Kidney Failure and Mortality in Patients With Type 2 Diabetes and CKD

RATIONALE & OBJECTIVE

Both glucagon-like peptide-1 receptor agonists (GLP-1RAs) and sodium/glucose cotransporter 2 (SGLT2) inhibitors improve cardiovascular, kidney, and survival outcomes in patients with type 2 diabetes; however, the comparative effectiveness of these drugs in a real-world setting remains unclear.

STUDY DESIGN

Retrospective cohort study.

SETTING & PARTICIPANTS

79,047 patients with type 2 diabetes and an eGFR <60 mL/min/1.73 m2 between 2016 and 2021 from the Taiwan's national health database.

EXPOSURE

Treatment with GLP1RA or treatment with SGLT2i.

OUTCOME

Initiation of kidney replacement therapy (KRT) and all-cause mortality.

ANALYTIC APPROACH

Propensity score matching was performed to balance baseline characteristics between the groups. Cox proportional hazards models were used to estimate hazard ratios (HRs) and 95% confidence intervals (CIs) for each outcome, using an intention-to-treat approach.

RESULTS

14,182 (7,091 initiating GLP1RA and 7,091 initiating SGLT2i) from the original cohort of 79,047 individuals were included in the propensity score-matched analysis. With a median follow-up duration of 2.5 years, people initiating GLP1RA had a higher risk of requiring KRT compared to those initiating SGLT2i (HR: 1.39, 95% CI: 1.19-1.63). Although tests of interaction were not statistically significant, stratified analyses suggested possibly greater differences between the two drugs among patients with eGFR <45 mL/min/1.73 m2 or urine albumin-to-creatinine ratio >300 mg/g. Overall mortality did not differ between treatment groups.

LIMITATIONS

Nonrandomized treatment selection.

CONCLUSIONS

Patients receiving SGLT2i demonstrated lower rates of progression to KRT compared to those receiving GLP1RA. These findings may inform the choice of these therapies in the setting of chronic kidney disease and type 2 diabetes.

Sexual Trauma, Suicide, and Overdose in a National Cohort of Older Veterans

BACKGROUND

Little is known about the association between military sexual trauma (MST) and risk for suicide-related outcomes later in life.

OBJECTIVE

To determine the association between MST and risk for suicide, overdose, and related mortality among older men and women at specific age landmarks and to investigate whether posttraumatic stress disorder (PTSD) modifies risk.

DESIGN

Longitudinal cohort study; baseline in 2012 to 2013, with follow-up through 31 December 2020.

SETTING

All U.S. Department of Veterans Affairs (VA) medical centers in the United States.

PARTICIPANTS

5 059 526 veterans aged 50 years or older.

MEASUREMENTS

Positive MST screening result, nonfatal suicide attempt, death by suicide, or overdose death.

RESULTS

MST was documented for 15.7% of older women and 1.3% of older men. The adjusted cumulative incidence of any suicide attempt was higher for those with MST (men, 18.67%; women, 8.66%) than for those without MST (men, 6.25%; women, 2.92%) at age 90 years. The adjusted risk differences among men and women were 12.41% (95% CI, 11.72% to 13.10%) and 5.74% (CI, 5.22% to 6.26%) for any late-life suicide attempt, 11.92% (CI, 11.27% to 12.57%) and 5.58% (CI, 5.08% to 6.08%) for nonfatal suicide attempt, 0.27% (CI, 0.00% to 0.54%) and 0.15% (CI, 0.00% to 0.30%) for fatal suicide attempt, and 1.05% (CI, 0.79% to 1.31%) and 0.48% (CI, 0.28% to 0.68%) for any drug overdose at age 90 years. MST remained a significant risk factor for any suicide attempt among people with and without PTSD.

LIMITATIONS

Selection bias, generalizability to non-VA veterans, possible unmeasured confounding, and missingness.

CONCLUSION

Late-life suicide attempt and death by suicide or overdose are associated with prior MST. These findings advance our understanding of the lasting effect of sexual trauma on suicide risk and mortality and suggest that monitoring and treatment of MST-related conditions are vital over the long term.

PRIMARY FUNDING SOURCE

VA Office of Research and Development.

Receipt of medications for opioid use disorders among veterans by race/ethnicity and legal involvement: an observational study of electronic health records

BACKGROUND

The Veterans Health Administration has made strides to improve access to medications for opioid use disorder overall. However, quality improvement methods to assess treatment gaps may not sufficiently detect differences in medication access by intersecting patient factors, which may have multiplicative rather than additive effects. This study aimed to determine whether race/ethnicity and legal involvement interact in receipt of medications for opioid use disorder among Veterans Health Administration patients.

METHODS

Using national electronic health record data from Fiscal Years 2021-2022, we examined the receipt of medications for opioid use disorder among veterans diagnosed with opioid use disorder who received healthcare at Veterans Health Administration facilities (n = 65,883). We conducted a mixed effects multivariable logistic regression model to examine an interaction effect of race/ethnicity and legal involvement with receipt of any medications for opioid use disorder, both unadjusted and adjusted for patient and facility characteristics.

RESULTS

In an adjusted logistic regression model, the interaction effect indicated that non-Hispanic Black veterans with legal involvement had the lowest odds of medications for opioid use disorder receipt compared to non-Hispanic White veterans without legal involvement (adjusted odds ratio = 0.67, 95% confidence interval = 0.59-0.77, p <.0001). Non-Hispanic American Indian/Alaska Native patients without legal involvement (adjusted odds ratio = 0.85, 95% confidence interval = 0.73-0.99, p =.04) also had lower odds of receipt of medications for opioid use disorder compared to non-Hispanic White patients without legal involvement. Non-Hispanic White veterans with legal involvement (adjusted odds ratio = 1.07, 95% confidence interval = 1.01-1.14, p =.03) had higher odds of receipt of medications for opioid use disorder compared to non-Hispanic White patients without legal involvement.

CONCLUSIONS

Veterans Health Administration quality improvement efforts should monitor interacting racial and legal status factors and understand and address patient, clinical, and regulatory barriers to medications for opioid use disorder among Black veterans with legal involvement.

Rural-urban disparities in hospitalisation for myocardial infarction in systemic lupus erythematosus in the USA

OBJECTIVE

To assess whether rural-urban disparities exist in people with SLE for hospitalisation with myocardial infarction (MI).

METHODS

We used the 2016-2019 US National Inpatient Sample data that contain all hospitalisation data. In people with a diagnosis of SLE, we assessed the multivariable adjusted ORs (aORs) to examine the association of rural patient residence with MI hospitalisation, while adjusting for demographics, payer, income, hospital characteristics and the Deyo-Charlson Comorbidity Index.

RESULTS

We found that the crude rates of patients hospitalised with MI per 100 000 area specific SLE hospitalisations were higher in rural versus urban residents with SLE, 2265 versus 1435 (p value<0.001). In the multivariable-adjusted model that accounted for demographics, insurance payer, household income, comorbidities and hospital characteristics including geographical location, we found that rural residence was associated with an aOR of 1.98 (95% CI, 1.71 to 2.29; reference category, urban residence) of MI hospitalisations in people with SLE. Other factors significantly associated with the risk of MI were male sex, Medicaid or private insurance, urban not teaching or urban teaching hospital, Midwest region and a private hospital control, either for profit or not for profit.

CONCLUSION

Rural residence doubled the risk of MI hospitalisation in people with SLE independent of demographics, payer status, social determinants of health and hospital characteristics. Our study highlights the disproportionate effect of rurality on health outcomes in people with SLE within the USA and a clear rural-urban gap disparity. Interventions to reduce this disparity are needed.

Treatment at Academic Facilities is Associated With Improved Survival in Late-Stage Colonic Neuroendocrine Tumors

INTRODUCTION

Colonic neuroendocrine tumors (NETs) are a rare disease entity requiring complex and multidisciplinary management, and the survival benefit of treatment facility type has not been determined.

MATERIALS AND METHODS

The National Cancer Database was queried from 2004 to 2021 to identify treatment trends and overall survival (OS) outcomes in patients with stages I-IV colonic NETs who underwent surgery at academic or non-academic facilities.

RESULTS

21,838 patients met the inclusion criteria; 71% were treated at non-academic facilities and 29% at academic facilities. Patients at academic facilities were significantly more likely to be younger (odds ratio [OR] 1.16), reside in a metropolitan area (OR 2.37), and travel farther for care (OR 7.35). Academic facilities were more likely to perform complex en bloc resection (OR 1.15) with more extensive lymphadenectomy (OR 1.42). Treatment at academic facilities was associated with a decreased risk of mortality (hazard ratio [HR] 0.89) on adjusted Cox models. Older age (HR 2.14), increased comorbidities (HR 2.22), uninsured status (HR 1.36), low socioeconomic status (HR 1.08), complex en bloc resection (HR 1.12), and increased nodal positivity (HR 2.42) significantly predicted increased mortality of the entire cohort; subgroup analysis found that low socioeconomic status and uninsured status were not significant predictors of survival at academic facilities. Kaplan-Meier analysis identified a benefit in median OS for those treated at an academic versus non-academic facility (161.1 versus 146.6 mo, P = 0.002). On subgroup Cox analyses by individual clinical stage, treatment at academic facilities was associated with a significantly decreased risk of mortality for patients with late-stage disease (stage III: HR 0.83, P = 0.005; stage IV: HR 0.84, P < 0.001); there was no significant difference in survival by treating facility type for early-stage disease (stage I: HR 1.05, P = 0.58; stage II: HR 0.87, P = 0.12).

CONCLUSIONS

Treatment at academic facilities is associated with a survival benefit for patients undergoing surgical resection for late-stage colonic NETs. Further research is needed to understand these survival differences to bridge the gap in care for patients with colonic NETs.

Quantification of Modifiable Risk Factors in Monoclonal Gammopathy of Undetermined Significance Progression to Multiple Myeloma

PURPOSE

Multiple myeloma (MM) is the most common plasma cell dyscrasia in the United States with notably significant health disparities. MM is preceded by an asymptomatic precursor monoclonal gammopathy of undetermined significance (MGUS). Studies have identified several risk factors for the progression of MGUS to MM; however, the relative contributions of these remain unknown. Particularly, understanding the contribution among those modifiable factors may inform MM prevention.

METHODS

This study quantified these contributions by estimating the adjusted population attributable fractions (aPAF) of modifiable risk factors for MM among the Veteran population with MGUS.

RESULTS

Among all evaluated risk factors, excess body mass index (BMI ≥25 kg/m 2 ) was the leading factor (Black: aPAF=27.0%, 95% CI 19.3-33.9%; White: 27.1%, 95% CI 20.3-33.4%; All: aPAF=27.1%, 95% CI: 22.0-31.8%).

CONCLUSION

Our study highlights the potential for weight management as a key strategy in reducing the risk of progression to MM in Black and White patients diagnosed with MGUS.

Artificial intelligence based assessment of clinical reasoning documentation: an observational study of the impact of the clinical learning environment on resident documentation quality

BACKGROUND

Objective measures and large datasets are needed to determine aspects of the Clinical Learning Environment (CLE) impacting the essential skill of clinical reasoning documentation. Artificial Intelligence (AI) offers a solution. Here, the authors sought to determine what aspects of the CLE might be impacting resident clinical reasoning documentation quality assessed by AI.

METHODS

In this observational, retrospective cross-sectional analysis of hospital admission notes from the Electronic Health Record (EHR), all categorical internal medicine (IM) residents who wrote at least one admission note during the study period July 1, 2018- June 30, 2023 at two sites of NYU Grossman School of Medicine's IM residency program were included. Clinical reasoning documentation quality of admission notes was determined to be low or high-quality using a supervised machine learning model. From note-level data, the shift (day or night) and note index within shift (if a note was first, second, etc. within shift) were calculated. These aspects of the CLE were included as potential markers of workload, which have been shown to have a strong relationship with resident performance. Patient data was also captured, including age, sex, Charlson Comorbidity Index, and primary diagnosis. The relationship between these variables and clinical reasoning documentation quality was analyzed using generalized estimating equations accounting for resident-level clustering.

RESULTS

Across 37,750 notes authored by 474 residents, patients who were older, had more pre-existing comorbidities, and presented with certain primary diagnoses (e.g., infectious and pulmonary conditions) were associated with higher clinical reasoning documentation quality. When controlling for these and other patient factors, variables associated with clinical reasoning documentation quality included academic year (adjusted odds ratio, aOR, for high-quality: 1.10; 95% CI 1.06-1.15; P <.001), night shift (aOR 1.21; 95% CI 1.13-1.30; P <.001), and note index (aOR 0.93; 95% CI 0.90-0.95; P <.001).

CONCLUSIONS

AI can be used to assess complex skills such as clinical reasoning in authentic clinical notes that can help elucidate the potential impact of the CLE on resident clinical reasoning documentation quality. Future work should explore residency program and systems interventions to optimize the CLE.

Opioid Tapering and Opioid Overdose, Opioid Use Disorder, and Mortality Among Older Adults: A Nested Case-Control Study

BACKGROUND

Opioid tapering has increased in recent years; however, evidence regarding its safety profile is lacking.

OBJECTIVE

To examine the relationships between opioid tapering and subsequent overdose (OD), opioid use disorder (OUD), and all-cause mortality among older adults on long-term opioid therapy (LTOT).

DESIGN

Nested case-control design.

PARTICIPANTS

A cohort of older (≥ 65 years) Medicare beneficiaries with chronic non-cancer pain who were on LTOT was identified from 2012-2020 5% national Medicare claims data.

MAIN MEASURES

The key independent variable was rate of opioid tapering, operationalized as a monthly dose change percentage with four levels: steady dose (± 10% dose change), slow tapering (10-40% dose reduction), rapid tapering (> 40% dose reduction), and dose escalation (> 10% dose increase). The outcome variables were OD, OUD, and all-cause mortality. Conditional logistic regression was conducted on matched samples to evaluate the associations between opioid tapering and the outcomes.

KEY RESULTS

Among a cohort of 82,295, 1333 cases of OD, 4933 cases of OUD, and 5971 cases of all-cause mortality were identified. In primary analyses, after controlling for all covariates, compared with steady dose, the odds of OD were significantly lower (aOR = 0.74; 95% CI = 0.55-0.99) for rapid tapering and significantly higher (aOR = 2.08; 95% CI = 1.64-2.65) for dose escalation. Compared to steady dose, the odds of OUD were significantly lower (aOR = 0.53; 95% CI = 0.46-0.60) for rapid tapering and significantly higher (aOR = 1.60; 95% CI = 1.42-1.81) for dose escalation. Compared to steady dose, significantly higher odds for all-cause mortality were found among patients undergoing rapid tapering (aOR = 1.28; 95% CI = 1.14-1.44), and dose escalation (aOR = 1.51; 95% CI = 1.34-1.71). Sensitivity analyses showed that mortality outcome is sensitive to variations in cohort selections.

CONCLUSION

The results suggest that any opioid dose change for patients on LTOT may negatively affect all-cause mortality. Clinicians should regularly assess patients on LTOT, considering the benefits and risks of treatment that incorporate evolving evidence on dose changes.

Incidence and risk profiles for pneumonia in patients with schizophrenia receiving home-care case management intervention in Taiwan

BACKGROUND

Home-care case management is a type of community outreach service. However, research on the incidence of infectious diseases in patients receiving home-care case management is limited. This study investigated the incidence of various infectious diseases and risk factors for pneumonia in patients with schizophrenia receiving home-care case management.

METHODS

We used data from Taiwan's National Health Insurance Research Database between January 1, 2000, and December 31, 2019, to construct a schizophrenia cohort receiving home-care case management (n = 19,687). Pneumonia was the most common infectious disease at follow-up (n = 3966). To identify risk factors for pneumonia, a nested case-control study was conducted. Risk-set sampling was conducted to randomly select controls for each pneumonia case. Conditional logistic regression was employed for statistical analysis.

RESULTS

Among various infectious diseases, pneumonia had the highest standardized incidence ratio in our cohort. Of the 3966 patients with pneumonia identified, 56.9% were men. After pairing, 3961 case-control pairs were established. Psychiatric comorbidities, specifically dementia and depressive disorders, were associated with a higher risk of pneumonia (adjusted incidence rate ratios [aIRRs] = 2.73 and 1.34, respectively). In contrast to oral antipsychotics, long-acting injectables were not associated with an increased pneumonia risk, suggesting that long-acting injectables could be a safer treatment option for patients with schizophrenia.

CONCLUSION

Our results revealed a significantly elevated pneumonia risk in this patient population, especially in those with physical and psychiatric comorbidities. The findings advocate for comprehensive care strategies to reduce the risk of pneumonia in this population.

Non-liver comorbidity in patients with hepatocellular carcinoma and curative treatments - a Swedish national registry study

OBJECTIVES

Treatment decisions for hepatocellular carcinoma (HCC) involve considering tumour stage, liver function and performance status, including comorbidities, although rarely analysed specifically. This study examines the patterns and prognostic impact of comorbidities in HCC patients.

METHODS

We included patients diagnosed with HCC before undergoing transplantation, resection or ablation, registered in the Swedish Registry for Cancers in the Liver and Bile ducts (SweLiv) 2008-2016. Data were cross-linked with the Swedish National Patient Registry (NPR) to capture International Classification of Diseases (ICD) codes reflecting comorbidities within 10 years before the HCC treatment decision. The Charlson Comorbidity Index (CCI), excluding the liver disease category (CCI-P), was used to estimate accumulated comorbidity.

RESULTS

We identified 980 HCC patients with transplantation (225), resection (425) or ablation (330). The comorbidity burden, assessed using the CCI-P, was highest in ablation patients and lowest in the transplanted group (p < 0.001). The CCI-P category distribution varied across treatment groups. After adjusting for age and tumour burden, several CCI-P categories were associated with 5-year mortality, including heart failure, cerebrovascular disease, pulmonary disease, ulcers, and renal disease. ICD diagnoses not included in the CCI, such as trauma, infection, psychiatric disease, anaemia, and obesity, were also linked to 5-year mortality.

CONCLUSIONS

Comorbidity burden and patterns differed between HCC treatment groups, with CCI-P significantly associated with mortality. Preoperative attention to cardiovascular disease is important, but other comorbid conditions may require vigilance. Given the higher prevalence of comorbidities in ablation and resection patients, efforts to optimize comorbidity in these groups may be warranted.

Medical Comorbidity and Male Sex Are Associated With Higher In-hospital Mortality for 90-Day Readmissions and Higher Readmission Rates After Nonelective Primary Total Hip Arthroplasty for Hip Fracture

PURPOSE

To assess whether sex and comorbidity are associated with the risk of 90-day readmission and associated mortality after nonelective primary total hip arthroplasty (THA) for hip fracture in the United States.

METHODS

We used the 2016-2019 US Nationwide Readmissions Database, a nationally representative dataset of readmissions, to examine 90-day readmission outcomes after primary nonelective THA with a primary diagnosis of hip fracture. Sex and medical comorbidity (Deyo-Charlson Comorbidity Index) were variables of interest. We adjusted for demographics (age), social determinants of health (income, region, insurance payer), and hospital characteristics (control, location/teaching status, bed size). We calculated adjusted odds ratio (aOR) and 95% confidence intervals (CIs) in multivariable-adjusted logistic regression analyses.

RESULTS

Of the 346,030 nonelective primary THAs for hip fracture performed in the United States, 61,443 (17.8%) had a 90-day readmission. For readmitted patients, the mean age was 80.2 years (SD, 9.6), 62.0% were women, and 90.6% had Medicare payer. In multivariable-adjusted analysis, compared with men, women had a lower aOR of 0.75 (95% CI, 0.73-0.77; p < 0.001) for 90-day readmission and lower aOR of 0.76 (95% CI, 0.69-0.84; p < 0.001) of in-hospital mortality during readmission, after nonelective primary THA for hip fracture. Deyo-Charlson index scores of 1 and ≥2 were associated with higher aOR of 90-day readmission at 1.53 (95% CI, 1.47-1.59; p < 0.001) and 2.20 (95% CI, 2.13-2.28; p < 0.001) and higher in-hospital mortality during readmission, 1.20 (95% CI, 1.01-1.42; p = 0.04) and 1.69 (95% CI, 1.40-1.97; p < 0.001), respectively.

CONCLUSION

In contemporary U.S. national data from 2016 to 2019, medical comorbidity and male sex were each associated with a higher risk of 90-day readmission and in-hospital mortality following primary nonelective THA for hip fracture. Further investigation into mechanisms and pathways of increased risk in men and those with higher medical comorbidity undergoing primary THA for hip fracture is needed, which can lead to the development of pathways for risk reduction and improved outcomes.

Dysglycemic Events after Initiation of Intermittently Scanned Continuous Glucose Monitoring in Patients with Insulin-Treated Type 2 Diabetes

Initiation of intermittently scanned continuous glucose monitors (isCGM) has been shown to reduce hemoglobin A1c (A1c) in patients with insulin-treated type 2 diabetes (T2D), but its effect on acute dysglycemic events (hypoglycemia and hyperglycemia) merits additional study. We conducted an observational, comparative effectiveness analysis of patients with insulin-treated T2D, comparing the efficacy of isCGM versus self-monitoring of blood glucose to improve glycemia and reduce acute dysglycemic events. We utilized a difference-in-differences framework to estimate pre-post changes in these outcomes, addressing confounding using overlap weighting based on propensity scores using rigorous causal analysis and machine learning. Initiating isCGM was associated with improved glycemia (reduced A1c, more patients with A1c <8% and <9%), but not the incidence of acute dysglycemic (hypoglycemic or hyperglycemic) events. This study on isCGM use is one of the largest to date and provides important information about the benefits of this technology in a population of patients with insulin-treated T2D.

In-Hospital Outcomes of Left Atrial Appendage Occlusion Among Cancer Patients with Atrial Fibrillation: A Nationwide U.S. Study

Background: Atrial fibrillation (AF) is frequently observed in cancer patients, driven by mutual comorbidities and increasing the risk of thromboembolic events. Impediments can hinder the utilization of anticoagulants among patients with malignancy-drug interactions with chemotherapy, renal dysfunction, drug intolerance, and increased bleeding risk. Left atrial appendage occlusion (LAAO) is an effective and safe non-pharmacological approach to prevent thromboembolic complications when anticoagulants are not suitable. Cancer patients were generally excluded from the original LAAO trials, and current safety and efficacy in cancer patients remain uncertain. Methods: This retrospective study utilized the National Inpatient Sample (NIS) database to analyze in-hospital outcomes of LAAO in US patients with and without cancer between 2016 and 2019. Patient demographics, comorbidities, procedures, and in-hospital outcomes were extracted using ICD-10-CM codes. Results: Among 12,273 hospitalizations for LAAO across the US representing an estimated 61,365 LAAO procedures, 2.2% (1365 cases) were performed in cancer patients. Older age, male gender, chronic kidney disease, prior stroke, and anemia were more prevalent in the cancer group, with 785 (58%) having a solid malignancy and 580 (42%) having a hematologic malignancy. Compared to non-cancer patients, cancer patients exhibited a higher rate of in-hospital complications (8.8% vs. 5.7%; p < 0.001), primarily driven by acute kidney injury (4.4% vs. 2.4%; p = 0.002), acute heart failure (3.7% vs. 2.6%; p = 0.012), and cardiac tamponade (1.5% vs. 0.8%; p = 0.006). No significant differences were observed in vascular complications, periprocedural stroke, or in-hospital mortality. Average length of stay (LOS) was longer in cancer patients (1.4 ± 2.7 days vs. 1.8 ± 2.5 days; p < 0.001). Conclusions: This nationwide study found that cancer patients undergoing LAAO had an increased rate of in-hospital complications, particularly acute kidney injury, heart failure, and tamponade, but no increase in in-hospital mortality was observed. Further research is needed to evaluate the long-term safety and efficacy of LAAO for managing embolic prevention in this complex patient population.

Association of Glucagon-Like Peptide-1 Receptor Agonist with Progression to Liver Cirrhosis and Alcohol-Related Admissions in Patients with Alcohol Use Disorder and Diabetes: A Retrospective Cohort Study

AIM

In recent years, use of glucagon-like peptide-1 receptor agonists (GLP-1RA) has exponentially increased due to their beneficial effects on weight loss and cardiovascular outcomes. Lately, some animal studies and observational data suggested that GLP-1RA may be useful in the treatment of alcohol use disorder (AUD). We aim to compare the risk of progression to liver cirrhosis and alcohol-related hospital admission after initiation of GLP-1RA versus dipeptidyl peptidase-4 inhibitors (DPP4i), as the active comparator, in patients with type 2 diabetes mellitus and AUD.

METHODS

We conducted a retrospective propensity score-matched cohort study, utilizing new-user and active comparator design. The study used data from the Veterans Health Administration during fiscal years 2006 to 2021 encompassing adults with AUD who initiated either GLP-1RA or DPP4i prescriptions. Our two co-primary outcomes were progression to cirrhosis (compensated and decompensated cirrhosis) and alcohol-related hospital admission.

RESULTS

The eligible cohort included 9965 GLP-1RA users and 19,688 DPP4i users. After propensity score matching, 7302 pairs were matched on 79 characteristics without residual imbalances. In the propensity score-matched cohort, progression to cirrhosis occurred in 6.6% of GLP-1RA users and 6.0% DPP4i users; odds ratio (OR): 1.1, 95% confidence interval (95% CI): 0.97-1.26. Alcohol-related hospital admission occurred in 1.4% of GLP-1RA users and in 1.7% of DPP4i users (OR: 0.85; 95% CI: 0.65-1.11).

CONCLUSIONS

Use of GLP-1RA in patients with AUD was not associated with beneficial effect on progression to cirrhosis or alcohol-related hospital admission.

Effect of age on major trauma profile and characterisation: Analysis from the national major trauma audit in Ireland

BACKGROUND

Major trauma (MT) is a significant cause of morbidity and mortality worldwide, with older adult patients facing unique challenges due to age-related vulnerabilities and higher risks of falls. This study aimed to investigate differences in trauma characteristics, injury mechanisms, and outcomes of older adults compared to all younger patients with MT on a national level.

METHODS

This retrospective cohort study analysed the national Major Trauma Audit data from 23,765 eligible patients with MT in Ireland of all ages and stratified into two age groups: those under 65 years (n = 12,620) and those aged 65 years or older (n = 11,145). The Major Trauma Audit follows the methodology of National Major Trauma Registry in the UK. Variables assessed included injury severity, comorbidities, length of stay (LOS), and mortality rates. Statistical comparisons were made between the two age groups.

RESULTS

Older adults represent 47 % of the total Irish patient population with MT, with a significantly higher proportion of females (56 %) compared to younger patients (31 %) (P<0.001). Falls of less than two meters were the leading mechanism of injury for older adults (82 %), while road traffic accidents (RTA) were more common among younger patients (25 %). Severe injuries were observed in 34 % of both age groups, but <10 % of older adults were received by a trauma team. Comorbidities were significantly more prevalent in older adults (75 %) compared to 39 % in younger patients, (P<0.001). Median hospital LOS was twelve days for older adults, compared to seven days for younger patients. Mortality rates were significantly higher among the older patient population, who were also more likely to be discharged to long-term care, (P<0.001).

CONCLUSION

In comparison to younger patients, the present study highlights that older adults who experience major trauma are frequently under-triaged as suspected MT, leading to delays in care, inadequate treatment, or worse clinical outcomes.

Impact of Racial Disparities on Treatment of Early Triple Negative Breast Cancer Among American Indians/Alaska Natives and Non-Hispanic Whites

BACKGROUND

Differences in patient and tumor characteristics among American Indian/Alaska Native (AI/AN) and non-Hispanic White (NHW) breast cancers (BC) adversely impact overall survival (OS) in AI/AN. The aims of this study were to: 1) investigate disparities in treatment of early triple negative breast cancers (TNBC); 2) assess differences in OS.

METHODS

A hospital-based, retrospective cohort study using the National Cancer Database included AI/AN and NHW women, 18 years or older, diagnosed with TNBC between 2010 and 2019, stages I-III. Propensity score matching (1:3 ratio) was used for age, year, and analytic stage at diagnosis.

RESULTS

A total of 489 AI/AN and 1465 available matched NHW women with TNBC were analyzed. Time to first treatment (TFT) was significantly longer for AI/AN (P = .005). Multivariate analysis revealed that longer TFT was associated with only higher Charlson-Deyo Score (CDS) (P = .014) and nonprivate insurance (P < .001), but not race (P = .568). Overall treatment compliance was similar (AI/AN - 89.6% vs. NHW - 92.2%, P = .074). Compliance was significantly associated with only insurance status (P < .001). On multivariate analysis OS did not differ by race (P = .687, HR = 1.06; 95% CI: 0.79-1.44). Cancer stage, CDS, insurance status, and treatment compliance were associated with worse OS.

CONCLUSION

In patients with TNBC, there was no difference in TFT, compliance with recommended treatment or OS among AI/AN in comparison to White women when matched for age, stage, and year of diagnosis. In order to improve BC survival, it is important to manage comorbid conditions and improve detection of cancer at earlier stages.

Minimally Invasive Overactive Bladder Therapy After Prolapse Surgery

IMPORTANCE

Associations between pelvic organ prolapse and overactive bladder exist, yet little is known regarding minimally invasive overactive bladder therapy use among older women following prolapse surgery.

OBJECTIVE

The aim of the study was to determine minimally invasive overactive bladder therapy use (onabotulinumtoxinA injection, percutaneous tibial nerve stimulation, sacral neuromodulation) in older women following prolapse surgery.

STUDY DESIGN

This was a retrospective cohort study of a 100% sample of fee-for-service Medicare beneficiaries who had prolapse surgery 2014-2015. The primary outcome was new minimally invasive overactive bladder therapy and the secondary outcome was new overactive bladder diagnosis within Medicare claims data, within 2 years of prolapse surgery. Data were stratified by surgery type (obliterative, apical, anterior/posterior, and apical with anterior/posterior). Modified Poisson regression models were used to calculate relative risk for each outcome.

RESULTS

Among the 58,841 beneficiaries who underwent prolapse surgery, 1,120 (1.9%) received minimally invasive overactive bladder therapy within 2 years. Among those who underwent prolapse surgery and did not have a preexisting diagnosis of overactive bladder, 9.2% (2,580/28,160) had a new overactive bladder diagnosis within 2 years. Factors associated with the increased adjusted relative risk (aRR) of new minimally invasive overactive bladder therapy included surgery type (apical aRR 1.6, 95% CI, 1.2-2.2 compared to obliterative repair), concomitant stress urinary incontinence surgery (aRR 1.3, 95% CI, 1.2-1.5), preexisting overactive bladder (aRR 4.1, 95% CI, 3.4-4.8), and frailty (mild to severe frailty aRR 3.4, 95% CI, 2.7-4.3 compared to not frail).

CONCLUSION

Rates of minimally invasive overactive bladder therapy following prolapse surgery were low in a national cohort of female Medicare beneficiaries despite a high prevalence of disease.

Impact of systematic intravascular imaging on the outcomes of complex and higher-risk percutaneous coronary intervention

BACKGROUND

Intravascular imaging (IVI) improves the outcomes of percutaneous coronary intervention (PCI). However, the benefit of a systematic approach versus an already higher usage rate remains unclear. This study investigates the short-term impact of systematic IVI utilization during PCI in a complex higher-risk interventional PCI (CHIP-PCI) center.

METHODS

This retrospective study analyzed all patients undergoing PCI at a single center between April 2018 and March 2024. Participants were divided into groups based on IVI usage (systematic IVI: ≥80 % of procedures; non-systematic IVI: <80 %). Study endpoints included procedural metrics and in-hospital outcomes.

RESULTS

We analyzed 5547 PCI procedures: 2529 in the non-systematic IVI group (2018-2020) and 3018 in the systematic IVI group (2021-2024). PCI was performed for multivessel disease in 835 patients (15.1 %), left main disease in 957 (17.3 %), and chronic total occlusion in 2040 (36.8 %). Mechanical circulatory support was used in 385 (6.9 %). Atherectomy and intravascular lithotripsy were performed in 1409 (25.4 %) and 249 (4.5 %), respectively. After propensity score matching, -2,305 pairs were evaluated. Procedural and fluoroscopy time were similar between groups, while air kerma (577 vs. 688 mGy, p < 0.001) and contrast volume (96 ± 45 vs. 100 ± 47 ml, p = 0.005) were lower in the systematic IVI group. Systematic IVI was also associated with reduced cardiac tamponade rates (0.8 % vs. 1.6 %, p = 0.015) without differences in other cardiac-related complications.

CONCLUSIONS

In this large cohort of CHIP-PCI procedures performed at a highly specialized center, systematic IVI implementation was associated with lower radiation dose and contrast volume, as well as lower incidence of cardiac tamponade, at the expense of a slightly prolonged procedural time.

Oral anticoagulant timing and hospitalization in newly diagnosed nonvalvular atrial fibrillation patients

Background

Non-valvular atrial fibrillation (NVAF) significantly increases ischemic stroke and systemic embolism (SE) risks. Despite the proven efficacy of oral anticoagulants (OAC) in reducing these risks, their underutilization highlights a gap in clinical practice. This study examined OAC utilization patterns within the first year after NVAF diagnosis in patients without prior OAC use and the association between the timing of OAC initiation and the risk of all-cause and stroke/SE-specific hospitalizations.

Methods

A retrospective cohort study was conducted using data from the Premier Healthcare Database and linked claims from 1/1/2017-3/31/2021. Patients newly diagnosed with NVAF, without prior OAC use, were included.

Results

Of 23,148 adults with newly diagnosed NVAF, 11,059 (47.8%) initiated OAC within one year. OAC users predominantly had cardiovascular disease and risk factors, whereas non-OAC users had higher rates of malignancy and dementia. Early OAC initiation (74.9% during the index visit) was linked to lower hospitalization risks compared to those initiating later (29.2% vs. 45.9% for all-cause, p-value < 0.001 and 1.3% vs. 2.6% for stroke/SE-specific, p-value < 0.001). Adjusted odds ratios for all-cause and stroke/SE hospitalization favored early initiation were 0.35 (95% CI: 0.32-0.39) and 0.34 (95% CI: 0.24-0.47), respectively.

Conclusions

This study highlights OAC underutilization in NVAF patients and suggests early initiation may lower hospitalization rates. The findings emphasize the need for further research into real-world compliance with OAC guidelines and call for further research to confirm the benefits of early initiation. Personalized management strategies that consider individual patient profiles are recommended.

Comparing major comorbidity indices as predictors of all-cause mortality in the Veterans Affairs health care system

OBJECTIVES

The Charlson Comorbidity Index (CCI), the Elixhauser Comorbidity Index (ECI), and the Functional Comorbidity Index (FCI) are validated clinical measures of comorbidity, but direct comparisons between these measures have rarely been studied especially in high-risk patient populations, such as homeless individuals. The US Department of Veterans Affairs (VA) offers large patient samples to compare these comorbidity measures as predictors of mortality using administrative and clinical records. We examined CCI, ECI, and FCI scores among veterans seeking VA healthcare services, including those experiencing homelessness, and compared their predictive value in relation to all-cause mortality risk.

STUDY DESIGN AND SETTING

Several VA databases from 2017 to 2021 were retrospectively linked, and 4,701,711 U S. veterans [308,553 with homelessness and 4,393,158 without homelessness] were evaluated over a median follow-up of 4.1 years, yielding 917,921 recorded deaths. Regression models were constructed, and Harrell's Concordance Statistic (HCS) was calculated that assessed the ability of z-transformed comorbidity scores to discriminate "high-risk" vs "low-risk" groups of patients for mortality risk, after adjustment for demographic and clinical characteristics.

RESULTS

In adjusted models, ECI (HCS: 0.76-0.77) and CCI (HCS: 0.75-0.76) were better able to discriminate "high-risk" vs "low-risk" groups than FCI (HCS: 0.72-0.75) among homeless and nonhomeless veterans. Compared to ECI and CCI, FCI was more strongly associated with homelessness.

CONCLUSION

CCI and ECI may be more predictive of all-cause mortality risk than FCI, although FCI may be a useful measure of functioning in homeless populations.

PLAIN LANGUAGE SUMMARY

The CCI, ECI, and FCI are clinical measures of comorbidity, but their direct comparisons have been limited, especially in high-risk patient populations like homeless individuals. This study examined CCI, ECI, and FCI scores among veterans seeking health care services at the US Department of Veterans Affairs and found that ECI and CCI were better at discriminating high-risk vs low-risk groups and predicting mortality among homeless and nonhomeless veterans.

Hand in hand with healthcare: A nationwide analysis of emergency department encounters for hand ailments

Background

Hand ailments are frequent reasons for emergency department (ED) visits in the United States. This study analyzed the incidence, causes, outcomes, predictors of hospitalization, and healthcare utilization patterns nationwide.

Methods

This retrospective cohort study utilized data from the Nationwide Emergency Department Sample and National Readmission Database from 2016 to 2021. It included patients with a principal diagnosis of hand or wrist complaints.

Results

The study included 29,109,534 ED visits for hand ailments. The mean patient age was 36 years. Most patients were Caucasian (61 %), healthy (89 % Charlson Comorbidity score of 0), male (57 %), and from lower income brackets (60 %). Most injuries were unintentional (71 %), with hand lacerations being the most common reason for presentation, followed by closed distal radius fractures. Most patients were discharged home (96 %). Predictors of admission included older age (adjusted odds ratio (aOR) per decade: 1.03; 95 % Confidence Interval (CI): 1.02-1.03; p < 0.01), higher Charlson index (aOR:1.69; CI:1.65-1.73; p < 0.01), Medicaid insurance or uninsured (aOR:1.26; CI:1.18-1.36, aOR:1.25; CI:1.16-1.36; p < 0.01, respectively), and presentation at level I metropolitan trauma teaching hospitals (aOR:3.48; CI:2.98-4.07; p < 0.01). Admission rates increased by 21 % in 2020 compared to 2016. Healthcare expenditure was a staggering $105 billion in total ED and inpatient hospitalization charges. Expenditure increased significantly, surpassing inflation-adjusted rates.

Conclusions

Our analysis of 29 million patients highlights the healthcare burden posed by hand ailments, with lacerations being the most prevalent concern in emergency settings. Admission and readmission rates were influenced by age, comorbidities, socioeconomic status, insurance type, and hospital characteristics. This study provides a basis for targeted interventions in patient outcome enhancement and resource allocation. Limitations include the reliance on ICD-10-CM coding in the absence of clinical data, which may impact the accuracy of case identification and classification.

Hospital experience with geriatric trauma impacts long-term survival

BACKGROUND

Hospital experience measured by geriatric trauma proportion (GTP) is associated with in-hospital mortality among geriatric patients. Our goal was to determine the impact of GTP on long-term survival among older trauma patients.

METHODS

This was a retrospective analysis of Medicare inpatient claims (2014-2015) of geriatric trauma patients admitted in Florida. GTP was calculated by dividing the number of geriatric trauma patients by the overall adult trauma volume in each hospital. Hospitals were then categorized into tertiles of GTP. Our main outcome was mortality at 30, 90, 180, and 365 days. Multivariable regression was performed to identify the association between GTP and long-term survival.

RESULTS

We included 65,763 geriatric trauma patients. As compared with hospitals in the lowest tertile, patients treated at the highest tertile were associated with lower mortality at 90 days (OR 0.90, 95%CI 0.82-0.98), 180 days (OR 0.90, 95%CI 0.83-0.97), and 365 days (OR 0.91, 95%CI 0.85-0.98).

CONCLUSIONS

Higher GTP is associated with improved long-term outcomes. However, mortality following trauma among geriatric patients continues to increase for 12 months.

Predictors of healthy days at home: Benchmarking long-term outcomes in geriatric trauma

BACKGROUND

Quality benchmarking has recently evolved from a historical focus on short-term morbidity and mortality as the key metrics to assessing long-term outcomes. Long-term quality metrics have been shown to provide a more complete assessment of geriatric trauma care. Among these metrics, patients' average number of healthy days at home (HDAH) proports to be a useful administrative claims-based marker of patient functional status. Our goal was to determine the predictors of HDAH among injured older adults.

METHODS

Medicare inpatient claims (2014-2015) were used to identify all geriatric trauma patients. Patients' number of HDAH was measured from the date of discharge and calculated as the total sum of patients' time during that period less any time spent in the hospital or emergency department, step-down/rehabilitation/nursing care, home health, or after death within a 365-period after index admission. Controlling for demographic, injury severity, and hospital-level characteristics, multivariable regression analyses were performed to identify the factors associated with increased HDAH.

RESULTS

We included 772,109 geriatric trauma patients. The mean age was 82.15 years (SD, 8.49 years), 68.3% were female, and 91.6% were White. The median HDAH was 351 days (interquartile range, 351-355 days). After adjusted analysis, age, Black race, Charlson Comorbidity Index (CCI), and care at a level 3/nontrauma center were associated with fewer HDAH within 365 days after discharge.

CONCLUSION

This study suggests that higher level trauma centers provide more HDAH after index admission for injured older adults. Future studies should focus on correlating HDAH with more granular but less readily accessible quality of life metrics.

LEVEL OF EVIDENCE

Prognostic and Epidemiological; Level III.

Real-world data of immune-related adverse events in lung cancer patients receiving immune-checkpoint inhibitors

BACKGROUND

Immune-checkpoint inhibitors (ICIs) have revolutionized lung cancer (LC) treatment; however, immune-related adverse effects (irAEs) may occur. The risk factors of irAEs and the impact of irAEs on patient outcomes in LC remain uncertain.

MATERIALS AND METHODS

irAEs within 12 months of ICI initiation in LC patients who initiated ICIs 2018-2021 were identified. Cause-specific Cox regression was used to assess risk factors for irAEs with the competing risk of death; a subset analysis was done among non-small cell lung cancer (NSCLC) group. Multivariable Cox regressions were used to evaluate the impact of irAEs on progression-free survival (PFS) and overall survival (OS).

RESULTS

Of 125 patients, 50 irAEs occurred in 39 patients. Small cell lung cancer (SCLC) histology was associated with a higher risk of irAEs (Hazard ratio (HR) = 2.73, 95% CI [1.17, 6.35], p = 0.020) than NSCLC. In NSCLC subset, programmed death-ligand 1 (PDL1) positivity (HR = 2.68, 95% CI [1.10. 6.53], p = 0.030) was identified as a risk factor. irAEs were not significantly associated with PFS (HR = 0.69, p = 0.204) or OS (HR = 0.72, p = 0.353).

CONCLUSION

SCLC histology and PDL1 positivity were associated with irAEs, and the occurrence of irAEs showed no impact on survival in LC patients. Future studies are required to validate the findings.

Nontraumatic Intracranial Hemorrhage and Risk of Incident Dementia in US Medicare Beneficiaries

BACKGROUND

To study the risk of incident dementia after a nontraumatic intracranial hemorrhage in a diverse US population and evaluate whether this risk is different for the subtypes of intracranial hemorrhage.

METHODS

We performed a retrospective cohort study using both inpatient and outpatient claims data on a 5% sample of Medicare beneficiaries per year between January 1, 2008 and December 31, 2018. The exposure was a new diagnosis of nontraumatic intracranial hemorrhage, defined as a composite of intracerebral hemorrhage, subarachnoid hemorrhage, and subdural hemorrhage. The outcome was a first-ever diagnosis of dementia. The exposure and outcomes were identified using validated International Classification of Diseases, Ninth and Tenth Revisions, Clinical Modification diagnosis codes. We excluded patients who had prevalent intracranial hemorrhage or dementia to ensure that only incident cases were counted in our analyses. In the primary analysis, we used Cox regression to study the risk of dementia after intracranial hemorrhage, after adjusting for demographics and comorbidities. In secondary analyses, the risks of dementia in different subtypes of intracranial hemorrhage were studied.

RESULTS

Among 2.1 million patients, 14 775 had a diagnosis of intracranial hemorrhage with an incidence rate of 1.2 (95% CI, 1.1-1.2) per 1000 person-years. Incident dementia was diagnosed in 2527 (17.1%) of the 14 775 patients with intracranial hemorrhage and in 260 691 (12.8%) of the 2 033 190 patients without intracranial hemorrhage. During a median follow-up of 5.6 (interquartile range, 3.0-9.0) years, the incidence rate of dementia was 8.6 (95% CI, 8.1-8.9) per 100 person-years among patients with intracranial hemorrhage and 2.2 (95% CI, 2.0-2.4) per 100 person-years among patients without intracranial hemorrhage. In an adjusted Cox regression analysis, intracranial hemorrhage was associated with an increased risk of incident dementia (hazard ratio, 2.0 [95% CI, 1.9-2.2]). In secondary analyses, a higher risk of incident dementia was observed with intracerebral hemorrhage (hazard ratio, 2.4 [95% CI, 2.2-2.5]), subarachnoid hemorrhage (hazard ratio, 1.99 [95% CI, 1.7-2.2]), and subdural hemorrhage (hazard ratio, 1.6 [95% CI, 1.4-1.7]).

CONCLUSIONS

In a large, heterogeneous cohort of elderly US participants, we found that intracranial hemorrhage was independently associated with a 2-fold increased risk of incident dementia. This elevated risk was consistently observed across subtypes of intracranial hemorrhage.

Patterns of recurrence among adults diagnosed with screen-detected lung cancer

BACKGROUND

With the recent shift in lung cancer staging towards early-stage disease coinciding with the introduction of lung cancer screening (LCS), little is known if LCS has affected the rate of recurrence and survival in community settings. Our objective was to evaluate variation in the detection and outcomes of recurrent lung cancer stratified by receipt of LCS.

METHODS

Patients aged 55-80 years old diagnosed with stage I-IIIA non-small cell lung cancer (NSCLC) between 1/1/2014 and 12/31/2020 who completed definitive therapy and were considered disease-free were identified. Rates of recurrence were calculated in discrete 12-month intervals and by cumulative incidence. Survival was evaluated by multivariable adjusted Restricted Mean Survival Time (aRMST). Factors associated with recurrence were evaluated by Poisson models.

RESULTS

Among 916 patients meeting study criteria, 708 (77 %) were non-screen-detected and 208 (23 %) were considered screen-detected. The proportion of recurrence between non-screen-detected (22 %) and screen-detected (17 %) was similar (P = 0.11). Recurrence rates during the first and second years after definitive therapy were 10.1 and 4.1 per 100 person-years for the non-screen-detected and 6.0 and 4.5 per 100 person-years for screen-detected, respectively. Two-year cumulative incidence of recurrence was 16.5 % (95 % CI, 13.9 %-19.4 %) for non-screen-detected patients and 13.8 % (95 % CI, 9.3 %-19.0 %) in the screen-detected group. Recurrence-free survival and survival after recurrence were similar between the two groups. Screening status was not associated with the likelihood of recurrence (RR=0.94, 95 % CI, 0.59-1.50).

CONCLUSION

These findings provide evidence of recurrence being a part of the intrinsic nature of disease progression despite mode of detection. Our findings emphasize the need for all patients to receive surveillance and survivorship care after treatment for early-stage NSCLC regardless of mode of detection. Further study with longer follow-up is warranted.

The Association between All-Cause Mortality and Obstructive Sleep Apnea in Adults: A U-Shaped Curve

Rationale: The relationship between sleep apnea (SA) and mortality remains a topic of debate. Objectives: We explored the relationship between the severity of SA and mortality and the effect of age on this association. Methods: Using a veterans' database, we extracted an apnea-hypopnea index (AHI) from physician interpretations of sleep studies by developing a natural language processing pipeline (with 944 manually annotated notes), which achieved more than 85% accuracy. We categorized the participants into no SA (n-SA; AHI, <5), mild to moderate SA (m-SA; 5 ⩽ AHI < 30), and severe SA (s-SA; AHI, ⩾30). We propensity-matched the m-SA and s-SA categories with n-SA on the basis of age, sex, race, ethnicity, body mass index, and 38 components of the Elixhauser Comorbidity Index. Using logistic regression, we estimated the odds ratio (OR) for all-cause mortality using m-SA as a reference. Also, we stratified the findings on the basis of age: young, ⩽40; middle aged, >40 and <65; and older, ⩾65 adults. Results: We extracted the AHI on 179,121 propensity-matched participants (mean age = 45.85 [SD = 14.1]; BMI = 30.15 ± 5.37 kg/m2; male, 79.09%; White, 64.5%). All-cause mortality rates among three AHI categories showed a U-shaped curve (11.55%, 7.07%, and 8.15% for n-SA, m-SA, and s-SA, respectively), regardless of age group. Compared with m-SA, the odds of all-cause mortality in n-SA (OR, 1.72; 95% confidence interval = 1.65-1.79) and s-SA (OR, 1.17; 95% confidence interval = 1.12-1.22) were higher. Stratifying by age yielded consistent findings. Conclusions: All-cause mortality showed a U-shaped association with the AHI. Further investigations to understand the underlying mechanisms of this phenomenon are warranted.

Adverse In-Hospital Outcomes Following Robot-Assisted vs. Open Radical Prostatectomy in Quadragenarians

Background/Objectives: Adverse in-hospital outcomes at radical prostatectomy have not been specifically addressed in young patients aged 40-49 years (quadragenarians). Additionally, no comparison between robot-assisted (RARP) vs. open radical prostatectomy (ORP) has been reported in this population. Methods: Descriptive analyses, propensity score matching (PSM), and multivariable logistic/Poisson regression models addressed quadragenarians undergoing RARP or ORP within the National Inpatient Sample (2009-2019). Results: Of 5426 quadragenarians, 4083 (75.2%) and 1343 (24.8%) underwent RARP and ORP, respectively. The proportion of RARP increased from 68.1 to 84.5% (2009-2019, EAPC: +2.8%, p < 0.001). Adverse in-hospital outcomes after RARP were invariably lower than those after ORP. Specifically, the rates of overall complications (7.8 vs. 13.4%, Δ -5.6%, multivariable odds ratio (OR): 0.54), blood transfusions (1.2 vs. 6.3%, Δ -5.1%, OR: 0.21), and length of stay (LOS) > 2 days (10.6 vs. 28.7%, Δ -18.1%, OR: 0.32) were lower after RARP than after ORP (all p < 0.001). After additional one-to-one PSM between ORP and RARP patients, virtually the same results were reported (overall complications: 7.0 vs. 13.4%, Δ -6.4%, OR: 0.49; blood transfusion rates: 1.5 vs. 6.3%, Δ -4.8%, OR: 0.23; LOS > 2 days: 10.9 vs. 28.7%, Δ -17.8%, OR: 0.30). Conversely, RARP use resulted in higher total hospital charges (USD 43,690 vs. 36,840, Δ USD +6850, IRR: 1.18; p < 0.001). Conclusions: Quadragenarians exhibited a more favorable adverse in-hospital outcome profile after RARP vs. ORP. These advantages are offset by a small, albeit significant, increase in total hospital charges.

The Combined Treatment of Chinese Herbal Medicines Is Correlated with a Lower Risk of Rheumatoid Arthritis in Patients with Depression: Evidence from a Population-Based Patient-Control Study

Background: Major depression places psychological strain on the individual that may increase the risk of developing rheumatoid arthritis (RA). Though the use of Chinese herbal medicines (CHMs) is widespread in clinical practice, its effect on the prevention of RA incidents is still unknown. This study aimed to evaluate the association between CHMs use by patients with depression and their subsequent risk of being diagnosed with RA. Methods: This nested case-control study used claims data from a nationwide insurance database. We identified patients aged 20-70 years with newly diagnosed depression and without pre-existing RA between 2002 and 2010. We enrolled those with RA onset occurring after depression by the end of 2013 (n = 973). Randomly matched controls were selected from the remaining patients with depression but without RA (n = 1946). Conditional logistic regression analysis was executed to assess the association between CHMs use and RA onset. Data are presented as p-values with the significance set at 0.05 and as odds ratios (ORs) with 95% confidence intervals (CIs). Results: In this study, we found that adding CHMs treatment to conventional antidepressants greatly decreased the subsequent risk of RA among patients with depression, with an ORs of 0.64 (95% CIs: 0.57-0.76). Those using CHMs for more than three years had the most striking benefit, with a 61% lower risk of RA. Notably, initiating CHMs within the first 2 years after depression onset resulted in the greatest decrease in the RA risk. Conclusion: Using CHMs with conventional antidepressant therapy reduced the RA risk among patients with depression. Further well-designed randomized controlled trials are needed to determine the molecular mechanism underlying the action of these herbal agents.

Early onset of hypertension and increased relative risks of chronic kidney disease and mortality: two population-based cohort studies in United Kingdom and Hong Kong

This study aimed to evaluate the association between hypertension (HT) onset age and later risks of chronic kidney diseases (CKD) and mortality. Adult patients without CKD from 2008 to 2013 were identified using electronic medical records from United Kingdom (UK) and Hong Kong (HK). Patients newly diagnosed with HT and those without were included in the HT and control groups, respectively. All subjects were stratified into six age groups (18-39, 40-49, 50-59, 60-69, 70-79, ≥80). Multivariable Cox proportional hazard regression, adjusted with baseline characteristics and fine stratification weights, was conducted to investigate the association between HT onset and risks of CKD, renal decline, end-stage renal disease (ESRD), and all-cause mortality. Subjects were followed up from baseline until an outcome event, death, or administrative end of the cohort, whichever occurred first. A total of 4,413,551 and 3,132,951 subjects were included in the UK and HK cohorts, respectively. HT was significantly associated with increased risks of outcome, but the hazard ratios (HRs) decreased with increasing onset age. In the UK cohort, the HRs (95% confidence intervals) for subjects aged 18-39 and ≥80 were 3.69 (3.53, 3.86) and 2.01 (1.96, 2.06) for CKD, 3.83 (3.60, 4.07) and 3.17 (2.97, 3.38) for renal decline, 17.26 (14.34, 20.77) and 2.55 (2.12, 3.07) for ESRD, 2.88 (2.66, 3.11) and 1.09 (1.07, 1.12) for mortality. The HK cohort exhibited a similar pattern. Our study concluded that early onset of HT significantly affects renal health later in life, while the contribution decreases with the onset age of HT.

Risk of Incident Mild Cognitive Impairment and Dementia Soon After Leaving Incarceration Among a US Veteran Population

OBJECTIVES

Increasing numbers of older adults are reentering community following incarceration (i.e., reentry), yet risk of incident neurodegenerative disorders associated with reentry is unknown. Our objective was to determine association between reentry status (reentry vs never-incarcerated) and mild cognitive impairment (MCI) and/or dementia.

METHODS

This nationwide, longitudinal cohort study used linked Centers for Medicare & Medicaid Services and Veterans Health Administration data. Participants were aged 65 years or older who experienced reentry between October 1, 2012, and December 31, 2018, with no preincarceration MCI/dementia, compared with age-matched/sex-matched never-incarcerated veterans. MCI/dementia was defined by diagnostic codes. Fine-Gray proportional hazards models were used to examine association.

RESULTS

This study included 35,520 veterans, mean age of 70 years, and approximately 1% women. The reentry group (N = 5,920) had higher incidence of MCI/dementia compared with the never-incarcerated group (N = 29,600; 10.2% vs 7.2%; fully adjusted hazard ratio [aHR] 1.12; 95% CI 1.00-1.25). On further investigation, reentry was associated with increased risk of dementia with or without prior MCI diagnosis (aHR 1.21; 95% CI 1.06-1.39) but not MCI only.

DISCUSSION

Transition from incarceration to community increased risk of neurocognitive diagnosis. Findings indicate health/social services to identify and address significant cognitive deficits on late-life reentry. Limitations include generalizability to nonveterans.

The role of a specialized memory clinic supporting primary care providers in a safety net health system

BACKGROUND

Although most dementia care occurs in primary care, consultation with dementia specialty care is sometimes indicated. Access to dementia specialists is limited, particularly in resource-limited environments such as the public health safety net, which may require triaging referrals to preserve access for patients with needs that can not be met in a primary care setting.

METHODS

The eConsult system for primary care providers to refer patients to a subspecialty memory clinic is described for a large safety net health system. Demographic and clinical characteristics are presented for patients evaluated within the memory clinic setting compared to the health system overall. ICD-10-CM codes were used to identify cognitive diagnoses and medical comorbidities. Chi-squared tests were used to compare categorical variables and t-tests for continuous variables.

RESULTS

94 individuals age 50 or older were seen in the memory clinic in 2019, of whom 43 were new evaluations. The most common visit diagnoses for new memory clinic patients were Alzheimer's disease (33%), no cognitive diagnosis (28%), unspecified dementia (19%), and mild cognitive impairment (12%); for follow up patients, the most common diagnoses were Alzheimer's disease (49%), unspecified dementia (18%), no cognitive diagnosis (14%), and mild cognitive impairment (10%). For those without a cognitive diagnosis, common visit diagnoses included cognitive symptoms, mood or sleep disorders, and metabolic disturbances. Of the 11 new internal referrals with a prior coded diagnosis of dementia, median time from first diagnosis to their initial memory clinic visit was 224 days.

CONCLUSIONS

Despite clear systemwide parameters for referral and extensive pre-referral screening via an eConsult system, the most common diagnosis for memory clinic patients was Alzheimer's disease. Direct studies of eConsult are needed to determine primary care providers' needs when referring patients with dementia to a memory clinic setting.

Decomposing Variations on Cluster Level for Binary Outcomes in Application to Cancer Care Disparity Studies

OBJECTIVE

To develop a method to decompose the observed variance of binary outcomes (proportions) aggregated by regional clusters to determine targets for quality improvement efforts to reduce regional variations.

DATA SOURCES AND STUDY SETTING

Data from the 2018 linkage of the Surveillance, Epidemiology, and End Results-Medicare database.

STUDY DESIGN

We developed a method to decompose the observed regional-level variance into four attributions: random, patients' characteristics, regional cluster, and unexplained. To demonstrate the efficacy of the method, we conducted a series of numerical studies. We applied this method to our cohort to analyze endocrine therapy receipt 3-5 years after diagnosis, using health service area (HSA) as the regional cluster.

DATA EXTRACTION METHODS

Our cohort included Stages I-III breast cancer patients diagnosed at ages 66-79 between 2007 and 2013 who received cancer surgery and were enrolled in Medicare Parts A and B.

PRINCIPAL FINDINGS

After decomposition, 39% of the total variation was explained by HSAs, which was higher than that in some other breast cancer measures, such as the proportion of Stage I at diagnosis (4%), previously reported. This suggests geospatial efforts have a great potential to address the regional variation regarding this measure.

CONCLUSIONS

Our variance decomposition method provides direct information about attributable variance in the proportions at a cluster level. This technique can help in the identification of intervention targets to improve regional variations in the quality of care and clinical outcomes.

Exposure to autoimmune disorders is associated with increased Alzheimer's disease risk in a multi-site electronic health record analysis

Autoimmunity has been proposed to increase Alzheimer's disease (AD) risk, but evaluating the clinical connection between autoimmune disorders and AD has been difficult in diverse populations. We investigate risk relationships between 26 autoimmune disorders and AD using retrospective observational case-control and cohort study designs based on electronic health records for >300,000 individuals at the University of California, San Francisco (UCSF) and Stanford University. We discover that autoimmune disorders are associated with increased AD risk (odds ratios [ORs] 1.4-1.7) across study designs, primarily driven by endocrine, gastrointestinal, dermatologic, and musculoskeletal disorders. We also find that autoimmune disorders associate with increased AD risk in both sexes, but the AD sex disparity remains in those with autoimmune disorders: women exhibit higher AD prevalence than men. This study identifies consistent associations between autoimmune disorders and AD across study designs and two real-world clinical databases, establishing a foundation for exploring how autoimmunity may contribute to AD risk.

Novel risk factors for venous thromboembolism following outpatient or inpatient transurethral resection of bladder tumors: Multivariable stepwise and LASSO regression modeling from us insurance claim database

INTRODUCTION AND OBJECTIVES

Transurethral resection of the bladder tumor (TURBT) is a standard procedure in bladder cancer (BC), which is associated with low risk of venous thrombo-embolism (VTE). The aim of this study was to find the predictors of postoperative VTE in patients undergoing TURBT for BC.

MATERIALS AND METHODS

In this retrospective cohort analysis, patients aged ≥ 18 years with BC diagnosis undergoing TURBT were identified in the Merative® Marketscan® Research de-identified databases in 2007-2021. Patients with prior VTE events were excluded. Preoperative diagnostic codes and outpatient prescriptions present in at least 1% of the cohort were recorded (205 variables). Then, logistic regressions were performed including each variable separately, all variables together, as well as variables selected by stepwise and Least Absolute Shrinkage and Selection Operator (LASSO) selection methods. Adjusted odds ratios (aOR) with 95% confidence intervals (CI) were calculated.

RESULTS

In total, 132,425 patients were included in this study, with 1959 (1.5%) individuals diagnosed with postoperative VTE. Various malignant neoplasms diagnosed before BC were significant risk factors of postoperative VTE, with aOR reaching up to 2.26 (95% CI: 1.96-2.61). Another strong predictor of VTE was a diagnosis of nephritis, nephrotic syndrome, and nephrosis (aOR 1.67, 95% CI: 1.48-1.87 stepwise; aOR 1.65, 95% CI: 1.46-1.85 LASSO). Also, patients with diseases of the urinary system, non-specific symptoms, diseases of the respiratory system, anemias, and other cardiovascular diseases were associated with increased VTE risk. Regarding drugs, antidiabetic agents and gastrointestinal drugs reduced the probability of VTE.

CONCLUSIONS

Numerous preoperative factors have influence on the risk of VTE after TURBT. These findings might facilitate the clinical decision about the implementation of thromboprophylaxis in the appropriate patients.

Current and historic patterns of chronic disease burden are associated with physical activity and sedentary behavior in older adults: an observational study

BACKGROUND

Cross-sectional studies suggest that chronic disease burden in older adults is associated with lower activity. However, preceding life-course patterns of morbidity accumulation may also influence current activity and have not been well characterized. Using a well-described sample of older adults, we estimated associations between current chronic disease burden and accelerometer-measured moderate-to-vigorous intensity movement measures, light-intensity movement measures, and sedentary behavior measures. Additionally, we examined historic morbidity patterns among those with current multimorbidity to provide additional understanding of these later life associations between current multimorbidity and activity.

METHODS

Analyses included N = 886 older adult study participants who wore activPAL and Actigraph accelerometers. We calculated Charlson Comorbidity Index (CCI; range 0-29) scores for participants at the time of device wear and estimated the association between current chronic disease burden (CCIcurrent) and each accelerometer-based activity metric using linear regression. Additionally, for participants categorized as having multimorbidity at time of device wear (CCIcurrent = 2+), we calculated CCI scores from age 55 through age at device wear. We plotted these to illustrate historic patterns of morbidity accumulation, and we compared activity metrics between participants with observed distal vs. recent onset of multimorbidity.

RESULTS

A unit increment in CCIcurrent was associated with higher mean sitting bout duration (0.5 min, CI: [0.0,1.0], p = 0.039) and with both lower average daily step counts (-319 steps, CI: [-431,-208], p < 0.001) and lower average daily minutes of moderate-to-vigorous physical activity (MVPA; -3.8 min, CI: [-5.2,-2.4], p < 0.001). No associations were seen with standing, light-intensity physical activity, or other sitting measures. Among older adults with multimorbidity at time of device-wear, results suggested some evidence that participants whose apparent onset was more distal engaged in less MVPA (-12.1, CI: [-21.0, -3.2], p = 0.008) and had fewer daily steps (-1000, CI: [-1745, -254], p = 0.009) than participants whose apparent onset was more recent.

CONCLUSIONS

Current chronic disease burden was associated with moderate-to-vigorous intensity movement measures and some patterns of prolonged sitting. Current multimorbidity is characterized by a preceding pattern of accumulation over the life-course. Attention to both current and historic trajectory of multimorbidity is important in investigations of MVPA and health.

The Effect of Chronic Kidney Disease on Adverse In-Hospital Outcomes at Radical Prostatectomy

OBJECTIVE

Radical prostatectomy (RP) may be a treatment option for prostate cancer in patients with chronic kidney disease (CKD). However, the effect of CKD on adverse in-hospital outcomes after RP is not well known.

METHODS

Descriptive analyses, propensity score matching (PSM), and multivariable logistic and Poisson regression models were used to address National Inpatient Sample RP patients between 2005 and 2019. CKD severity was stratified as mild (stage I/II) versus moderate (stage III) versus severe (stage IV/V).

RESULTS

Of 191 050 RP patients, 4349 (2.3%) had CKD. Of those, 2301 (52.9%), 1416 (32.6%), and 632 (14.5%) were classified as mild, moderate, or severe CKD, respectively. The CKD rate increased from 0.3% to 5.6% (2005-2019, EAPC: + 15.3%, p < 0.001). CKD patients invariably exhibited higher rates of adverse in-hospital outcomes, except for in-hospital mortality. The absolute differences were largest for overall complications (+ 12.5%), length of stay > 2 days (+ 11.8%), and blood transfusions (+ 3.7%, all p < 0.001). CKD was an independent predictor in all comparisons except for in-hospital mortality (p < 0.05). The detrimental effect was most pronounced for dialysis for acute kidney failure (multivariable odds ratio [OR] 10.49), genitourinary complications (OR: 2.47), and critical care therapies (OR: 2.45, all p < 0.001). Finally, a dose-response relationship of CKD severity (mild vs. moderate vs. severe) and its effect on adverse in-hospital outcomes was observed in seven of 14 comparisons.

CONCLUSIONS

CKD patients invariably exhibited higher rates of adverse in-hospital outcomes after RP. The presence of CKD should be carefully considered when RP represents a management option.

Healthcare resource utilization and associated cost in patients with metastatic non-small cell lung cancer treated in the immunotherapy era

BACKGROUND

Treatment approach for metastatic non-small cell lung cancer (mNSCLC) has revolutionized in the recent decade with the introduction of immunotherapy and targeted medications in first-line (1L) therapy. We present real-world data on clinical outcomes and direct healthcare resource utilization (HCRU) and cost in a 2.7-million-member Israeli health provider.

PATIENTS AND METHODS

Newly diagnosed mNSCLC patients between January 2017 and December 2020 were categorized by 1L treatment: platinum-based chemotherapy, targeted therapy, or immunotherapy. HCRU and costs were calculated based on the Ministry of Health Prices and were assessed at a minimum of 6 months' follow-up (cutoff: 30 June 2021).

RESULTS

A total of 886 patients were included in the study: 40.6% female, median age 68 years (IQR 61-74), 24.3% never smokers, 80.6% with adenocarcinoma, and 54% with a 0-1 performance status. The median follow-up was 27.12 months (95% CI, 24.7-29.6) and the median duration of first-line (1L) treatment was 2.3 months for platinum-based chemotherapy (n = 177), 12.3 months for targeted therapy (n = 255), and 4.8 months for immunotherapy (n = 463). The median overall survival was 9.09, 27.68, and 12.46 months, respectively. Total 1L costs were driven by radiotherapy for platinum-based chemotherapy and medication for targeted therapy or immunotherapy. Total costs for deceased patients over the entire follow-up were €121 155, €129 458, and €110 716, respectively.

CONCLUSION

The treatment of mNSCLC carries a high economic burden, primarily driven by first-line therapy, especially with targeted and immune therapies. Further studies are needed to evaluate the impact of innovative treatments on the disease management costs of mNSCLC.

Risk of acute kidney injury after percutaneous coronary intervention with plaque modification

BACKGROUND

The use of plaque modification techniques during percutaneous coronary interventions (PCI) has increased. However, these procedures are linked to higher contrast volume and hypotensive episodes, which are risk factors for acute kidney injury (AKI). This study examined the effects of various plaque modification techniques on AKI after PCI.

METHODS

We conducted a retrospective analysis of patients who underwent PCI at our institution between December 2020 to March 2024, categorizing them into 3 groups based on the plaque modification technique used: atherectomy, intravascular lithotripsy (IVL), or no plaque modification (NPM). The primary endpoint was AKI, and multivariable logistic regression was used to identify independent predictors of AKI. Multivariable analysis and propensity score matching (1:1) were performed to control for confounders.

RESULTS

In total, 1758 patients were included. Atherectomy was performed in 268 (15.2 %) patients, IVL in 120 (6.8 %) patients, and 1370 (77.9 %) patients had NPM. Atherectomy patients were older and had worse baseline renal function than the IVL and NPM groups (p < 0.001 for both). Compared with NPM, atherectomy was an independent predictor of AKI (odds ratio [OR] 1.27, 95 % confidence interval [CI] 1.07-1.98, p = 0.037), while IVL was not (OR 1.30, 95 % CI 0.84-2.08, p = 0.209). In a propensity-matched analysis of 101 atherectomy and IVL patient pairs, atherectomy-based PCI remained associated with a higher rate of AKI (11.9 % vs. 2.0 %; p = 0.013).

CONCLUSION

Atherectomy, but not IVL, is associated with a higher risk of AKI after PCI, compared to NPM. This underscores the importance of thoughtfully selecting plaque modification strategies in high-risk patients to reduce renal adverse events following PCI.

Metformin Use and Clinical Outcomes in Autosomal Dominant Polycystic Kidney Disease: A Nationwide Cohort Study

Background/Objectives: Autosomal dominant polycystic kidney disease (ADPKD) is a progressive genetic disorder marked by bilateral renal cysts and extrarenal manifestations, ultimately resulting in renal failure. Emerging research indicates that metformin might influence the intracellular mechanisms of ADPKD, though its clinical significance remains uncertain. Methods: We applied the Taiwan National Health Insurance Database (NHIRD) to investigate the clinical impact of metformin utilization in ADPKD patients in real-world practice. The metformin user group was defined by more than 90 days of usage. To mitigate selection bias, we established a non-user group with a 1:2 ratio, matching for age, sex, and comorbidities by a propensity score matching method. Results: A total of 10,222 ADPKD cases were identified in the NHIRD between 2009 and 2018. After matching, the metformin user group was composed of 778 cases with a mean age of 59.5 ± 13.9 years, and the non-user group of 1546 cases with a mean age of 59.3 ± 14.4 years. The time from the index date to the outcome of ESKD in ADPKD was 5.3 ± 2.2 years in the metformin user group and 5.3 ± 2.3 years in the metformin non-user group, respectively. The metformin user group exhibited a significant reduction in the risk of end-stage kidney disease (ESKD), as indicated in the fully adjusted model (0.75, 95% CI 0.58-0.97, p = 0.03). A decreased risk of major adverse cardiovascular events (MACEs) was noted in metformin users, with an adjusted hazard ratio (HR) of 0.78 (95% CI 0.65-0.95, p = 0.01). Sensitivity analysis showed similar results by excluding late-stage CKD (CKD stage 5 or erythropoietin-stimulating agents use). Conclusions: Metformin usage in real-world practice showed lower hazards of ESKD and MACEs in patients with ADPKD, except for those with advanced CKD.

Effect of Race/Ethnicity on In-hospital Outcomes After Radical Cystectomy

OBJECTIVE

Previously, African American race/ethnicity predisposed to higher rate of adverse in-hospital outcomes after radical cystectomy (RC). We tested whether this association applies to contemporary RC patients.

METHODS

Patients were identified within the National Inpatient Sample (NIS 2000-2019). Multivariable logistic and Poisson regression models were fitted.

RESULTS

Of 19,370 RC patients, 1,089 (5.6%) were African American, while 18,281 (94.4%) were Caucasian. Relative to Caucasians, African Americans were younger (median age 66 vs. 70 years; p < 0.001), more frequently female (33.8 vs. 18.5%; p < 0.001) and more frequently in the lowest income quartile (46.8 vs. 18.6%; p < 0.001). Relative to Caucasians, after RC, African Americans exhibited higher rates of postoperative complications (61.3 vs. 58.3%; multivariable odds ratio [MOR] 1.2; p = 0.009). Specifically, African Americans exhibited higher rates of blood transfusions (30.2 vs. 24.1%; MOR 1.3; p < 0.001), gastrointestinal (26.7 vs. 24.1%; MOR 1.2; p = 0.003), and infectious (6.2 vs. 4.2%; MOR 1.5; p = 0.001) complications, as well as deep vein thrombosis (3.1 vs. 1.7%; MOR 1.9; p < 0.001). Additionally, after RC, African Americans exhibited higher rates of critical care therapy use (CCT; 13.9 vs. 12.2%; MOR 1.3; p = 0.002) and in-hospital mortality (2.8 vs. 1.7%; MOR 1.8; p = 0.002). Finally, African Americans exhibited higher rates of length of stay ≥ 75th percentile (40.9 vs. 31.2%; MOR 1.6; p < 0.001).

CONCLUSIONS

In contemporary RC patients, African American race/ethnicity predisposes to less favorable in-hospital outcomes, including higher in-hospital mortality and longer hospital stay. Unfortunately, these race/ethnicity disadvantages have not been improved upon relative to the previous report.