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Neuman T, Corrado R, Banaag A, Koehlmoos TP. Utilization of antiobesity medications within the Military Health System. Obesity (Silver Spring) 2024. [PMID: 39089987 DOI: 10.1002/oby.24097] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2024] [Revised: 05/16/2024] [Accepted: 05/23/2024] [Indexed: 08/04/2024]
Abstract
OBJECTIVE The prevalence of overweight and obesity among beneficiaries of the Military Health System (MHS) is 41.6% and 30.5%, respectively. This incurs significant medical, fiscal, and military readiness costs. It is not currently known how the utilization of antiobesity medications (AOMs) within the MHS compares with that in the Veterans Health Administration or the private sector. Our aim was to assess the utilization of AOMs within the MHS. METHODS A cross-sectional study was conducted using data gathered from the MHS Data Repository and the inclusion of all adult TRICARE Prime and Plus beneficiaries ages 18 to 64 years who were prescribed at least one TRICARE-approved AOM during the years 2018 to 2022. RESULTS The total study population included 4,414,127 beneficiaries, of whom 1,871,780 were active-duty service members. The utilization of AOMs among the eligible population was 0.56% (0.44% among active-duty personnel). Liraglutide was the most-prescribed AOM (36% of the total). Female sex, age greater than or equal to 30 but less than 60 years, and enlisted or warrant officer rank were all associated with statistically significant higher odds of receiving AOMs. CONCLUSIONS Comparable with the US private sector, the MHS significantly underutilizes AOMs, including among active-duty service members, despite coverage of AOMs since 2018.
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Affiliation(s)
- Taylor Neuman
- Department of Preventive Medicine and Biostatistics, Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA
- Walter Reed National Military Medical Center, Bethesda, Maryland, USA
| | - Richele Corrado
- Walter Reed National Military Medical Center, Bethesda, Maryland, USA
- Department of Medicine, Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA
| | - Amanda Banaag
- Center for Health Services Research, Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA
- The Henry M. Jackson Foundation for the Advancement of Military Medicine, Bethesda, Maryland, USA
| | - Tracey Perez Koehlmoos
- Department of Preventive Medicine and Biostatistics, Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA
- Center for Health Services Research, Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA
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Schoenfeld AJ, Cirillo MN, Gong J, Bryan MR, Banaag A, Weissman JS, Koehlmoos TP. Development of Chronic Pain Conditions Among Women in the Military Health System. JAMA Netw Open 2024; 7:e2420393. [PMID: 38967922 PMCID: PMC11227075 DOI: 10.1001/jamanetworkopen.2024.20393] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2024] [Accepted: 05/06/2024] [Indexed: 07/06/2024] Open
Abstract
Importance The incidence of chronic pain has been increasing over the last decades and may be associated with the stress of deployment in active-duty servicewomen (ADSW) as well as women civilian dependents whose spouse or partner served on active duty. Objective To assess incidence of chronic pain among active-duty servicewomen and women civilian dependents with service during 2006 to 2013 compared with incidence among like individuals at a time of reduced combat exposure and deployment intensity (2014-2020). Design, Setting, and Participants This cohort study used claims data from the Military Health System data repository to identify ADSW and dependents who were diagnosed with chronic pain. The incidence of chronic pain among individuals associated with service during 2006 to 2013 was compared with 2014 to 2020 incidence. Data were analyzed from September 2023 to April 2024. Main Outcomes and Measures The primary outcome was the diagnosis of chronic pain. Multivariable logistic regression analyses were used to adjust for confounding, and secondary analyses were performed to account for interactions between time period and proxies for socioeconomic status and combat exposure. Results A total of 3 473 401 individuals (median [IQR] age, 29.0 [22.0-46.0] years) were included, with 644 478 ADSW (18.6%). Compared with ADSW in 2014 to 2020, ADSW in 2006 to 2013 had significantly increased odds of chronic pain (odds ratio [OR], 1.53; 95% CI, 1.48-1.58). The odds of chronic pain among dependents in 2006 to 2013 was also significantly higher compared with dependents from 2014 to 2020 (OR, 1.96; 95% CI, 1.93-1.99). The proxy for socioeconomic status was significantly associated with an increased odds of chronic pain (2006-2013 junior enlisted ADSWs: OR, 1.95; 95% CI, 1.83-2.09; 2006-2013 junior enlisted dependents: OR, 3.05; 95% CI, 2.87-3.25). Conclusions and Relevance This cohort study found significant increases in the diagnosis of chronic pain among ADSW and civilian dependents affiliated with the military during a period of heightened deployment intensity (2006-2013). The effects of disparate support structures, coping strategies, stress regulation, and exposure to military sexual trauma may apply to both women veterans and civilian dependents.
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Affiliation(s)
- Andrew J. Schoenfeld
- Center for Surgery and Public Health, Department of Orthopaedic Surgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
| | - Madison N. Cirillo
- Henry M. Jackson Foundation for the Advancement of Military Medicine, Bethesda, Maryland
| | - Jonathan Gong
- Department of Orthopaedic Surgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
| | | | - Amanda Banaag
- Henry M. Jackson Foundation for the Advancement of Military Medicine, Bethesda, Maryland
| | - Joel S. Weissman
- Center for Surgery and Public Health, Department of Surgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
| | - Tracey P. Koehlmoos
- Center for Health Services Research, Uniformed Services University of the Health Sciences, Bethesda, Maryland
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Mantey DS, Omega-Njemnobi O, Montgomery L, Kelder SH. Racial and Ethnic Disparities in Adolescent Combustible Tobacco Smoking From 2014 to 2020: Declines Are Lagging Among Non-Hispanic Black Youth. Nicotine Tob Res 2024; 26:940-947. [PMID: 38181207 PMCID: PMC11190047 DOI: 10.1093/ntr/ntae001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2022] [Revised: 11/20/2023] [Accepted: 12/20/2023] [Indexed: 01/07/2024]
Abstract
INTRODUCTION We quantified the linear trend in combustible tobacco smoking among adolescents in the United States from 2014 to 2020, and then compared these trends across racial and ethnic categories. We also tested the effect of e-cigarette use on these trends for all-youth and across racial and ethnic categories. AIMS AND METHODS We pooled and analyzed seven years of National Youth Tobacco Survey data for n = 124 151 middle and high school students from 2014 to 2020. Weighted logistic regression analyses calculated the annual change in combustible tobacco smoking (ie cigarettes, cigars, and hookah) from 2014 to 2020. Stratified analyses examined linear trends for non-Hispanic White (NHW), NH-Black (NHB), Hispanic/Latino, and NH-Other (NHO) youth. All-models controlled for sex, grade level, and past 30-day e-cigarette use. RESULTS Combustible tobacco smoking from 2014 to 2020 dropped by more than 50% for NHW youth, more than 40% for Latino and NHO youth, compared to just 16% among NHB youth. From 2014 to 2020, the odds of combustible tobacco smoking declined by 21.5% per year for NHWs, which was significantly greater than Hispanic/Latinos (17% per year; p = .025), NHOs (15.4% per year; p = .01), and NHBs (5.1% per year; p < .001), adjusting for sex, grade, and e-cigarette use. Trends and disparities in trends by race and ethnicity were observed independent of e-cigarette use. CONCLUSIONS Combustible tobacco smoking declined for all-youth but at significantly different rates across races and ethnicities. Notably, declines in combustible tobacco smoking are lagging among NHB youth. Interventions are critically needed to address this disparity. IMPLICATIONS A direct, evidence-based intervention to reduce combustible tobacco smoking among NHB youth is critically needed. Such tobacco control initiatives should follow the Best Practices for Comprehensive Tobacco Control Framework, incorporating sustainable funding for school-based intervention, public health education, and adult cessation.
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Affiliation(s)
- Dale S Mantey
- Department of Health Promotion and Behavioral Science, UTHealth University of Texas School of Public Health, Houston, TX, USA
- Michael and Susan Dell Center for Healthy Living, UTHealth School of Public Health, Austin Campus, Austin, TX, USA
| | - Onyinye Omega-Njemnobi
- Michael and Susan Dell Center for Healthy Living, UTHealth School of Public Health, Austin Campus, Austin, TX, USA
- Department of Epidemiology, Human Genetics and Environmental Sciences, UTHealth University of Texas School of Public Health, Houston, TX, USA
| | - LaTrice Montgomery
- Addiction Sciences Division, Department of Psychiatry and Behavioral Neuroscience, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Steven H Kelder
- Michael and Susan Dell Center for Healthy Living, UTHealth School of Public Health, Austin Campus, Austin, TX, USA
- Department of Epidemiology, Human Genetics and Environmental Sciences, UTHealth University of Texas School of Public Health, Houston, TX, USA
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Tower S, Banaag A, Adams RS, Janvrin ML, Koehlmoos TP. Analysis of Alcohol Use and Alcohol Use Disorder Trends in U.S. Active-Duty Service Women. J Womens Health (Larchmt) 2024. [PMID: 38682265 DOI: 10.1089/jwh.2023.0497] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/01/2024] Open
Abstract
Introduction: Alcohol use (AU) and disorders (AUDs) have been increasing among women over the past decade, with the largest increases among women of child-bearing age. Unprecedented stressors during the COVID-19 pandemic may have impacted AU for women with and without children. Little is known about how these trends are impacting women in the military. Methods: Cross-sectional study of active-duty service women (ADSW) in the U.S. Army, Air Force, Navy, and Marine Corps during fiscal years (FY) 2016-2021. We report the prevalence of AU and AUD diagnoses by FY, before/during the COVID-19 pandemic (2016-2019; 2020-2021, respectively), and by parental status. Log-binomial and logistic regressions examined associations of demographics, military, and family structure characteristics, with AU and AUD, during pre-COVID-19 and COVID-19 timeframes. Results: We identified 281,567 ADSW in the pre-COVID-19 period and 237,327 ADSW in the during COVID-19 period. The prevalence of AU was lower during the COVID-19 period (47.9%) than during the pre-COVID-19 period (63.0%); similarly, the prevalence of AUD was lower during the COVID-19 period (2.7%) than during the pre-COVID period (4.0%). ADSW with children had larger percentage decreases during the COVID-19 period. ADSW with children had a consistently lower prevalence and odds of AUD compared with ADSW without children in the pre- and during COVID-19 periods. Conclusion: Decreasing trends in AU and AUD among ADSW were unexpected. However, the prevalence of AU and AUD may not have been accurately captured during the COVID-19 period due to reductions in access to care. Continued postpandemic comparison of AU/AUD among women by parental status and demographic factors may guide targeted health efforts.
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Affiliation(s)
- Stephanie Tower
- Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA
| | - Amanda Banaag
- Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA
- The Henry M. Jackson Foundation for the Advancement of Military Medicine Inc., Bethesda, Maryland, USA
| | - Rachel Sayko Adams
- Boston University School of Public Health, Department of Health Law, Policy and Management, Boston, Massachusetts, USA
| | - Miranda Lynn Janvrin
- Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA
- The Henry M. Jackson Foundation for the Advancement of Military Medicine Inc., Bethesda, Maryland, USA
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Schoenfeld AJ, Munigala S, Gong J, Schoenfeld RJ, Banaag A, Coles C, Koehlmoos TP. Reductions in sustained prescription opioid use within the US between 2017 and 2021. Sci Rep 2024; 14:1432. [PMID: 38228721 DOI: 10.1038/s41598-024-52032-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2023] [Accepted: 01/12/2024] [Indexed: 01/18/2024] Open
Abstract
Over the last decade, various efforts have been made to curtail the opioid crisis. The impact of these efforts, since the onset of the COVID-19 pandemic, has not been well characterized. We sought to develop national estimates of the prevalence of sustained prescription opioid use for a time period spanning the COVID-19 pandemic (2017-2021). We used TRICARE claims data (fiscal year 2017-2021) to identify patients who were prescription opioid non-users prior to receipt of a new opioid medication. We evaluated eligible patients for subsequent sustained prescription opioid use. The prevalence of sustained prescription opioid use during 2020-2021 was compared to 2017-2019. We performed multivariable logistic regression analyses to adjust for confounding. We performed secondary analyses that accounted for interactions between the time period and age, as well as a proxy for socioeconomic status. We determined there was a 68% reduction in the odds of sustained prescription opioid use (OR 0.32; 95% CI 0.27, 0.38; p < 0.001) in 2020-2021 as compared to 2017-2019. Significant reductions were identified across all US census divisions and all patient age groups. In both time periods, the plurality of encounters associated with initial receipt of an opioid that culminated in sustained prescription opioid use were associated with non-specific primary diagnoses. We found significant reductions in sustained prescription opioid use in 2020-2021 as compared to 2017-2019. The persistence of prescribing behaviors that result in issue of opioids for poorly characterized conditions remains an area of concern.
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Affiliation(s)
- Andrew J Schoenfeld
- Department of Orthopaedic Surgery, Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA, 02115, USA.
| | - Satish Munigala
- Department of Preventive Medicine and Biostatistics, Uniformed Services University of the Health Sciences, 4301 Jones Bridge Road, Bethesda, MD, 20814, USA
| | - Jonathan Gong
- Department of Orthopaedic Surgery, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA, 02115, USA
| | | | - Amanda Banaag
- Department of Preventive Medicine and Biostatistics, Uniformed Services University of the Health Sciences, 4301 Jones Bridge Road, Bethesda, MD, 20814, USA
| | - Christian Coles
- Department of Preventive Medicine and Biostatistics, Uniformed Services University of the Health Sciences, 4301 Jones Bridge Road, Bethesda, MD, 20814, USA
| | - Tracey P Koehlmoos
- Department of Preventive Medicine and Biostatistics, Uniformed Services University of the Health Sciences, 4301 Jones Bridge Road, Bethesda, MD, 20814, USA
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Yockey RA, Barnett TE. Distracted and Impaired Driving Among U.S. Adolescents, 2019, USA. Health Promot Pract 2024; 25:60-64. [PMID: 36635873 DOI: 10.1177/15248399221150814] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
Distracted driving, the act of focusing on something else while operating a vehicle, is a significant health problem among adolescents. Although some studies have reported on prevalence among adolescents in the United States, limited studies have examined differences by sexual identity status. The purpose of the present study was to examine past 30-day distracted driving by sexual identity status among a large, national sample of adolescents ages 14 to 18 years. A secondary analysis was conducted on the 2019 Youth Risk Behavioral Surveillance System (YRBSS) data, and associations between distracted driving and demographics (e.g., biological sex, age, race/ethnicity) were assessed with weighted logistic regression analyses. A total of 13,590 adolescents ages 14 to 18 years were part of the final analytic sample. Twenty-three percent of adolescents reported distracted driving in the past 30 days. Compared with heterosexual adolescents, gay/lesbian (14.3%), bisexual (18.1%), and questioning (12.9%) adolescents reported lower distracted driving in the past 30 days. Findings through a health equity approach may inform harm reduction efforts and behavioral interventions.
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Affiliation(s)
- R Andrew Yockey
- University of North Texas Health Science Center, Fort Worth, TX, USA
| | - Tracey E Barnett
- University of North Texas Health Science Center, Fort Worth, TX, USA
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Dufour S, Banaag A, Schoenfeld AJ, Adams RS, Koehlmoos TP, Gray JC. Diagnostic profiles associated with long-term opioid therapy in active duty servicemembers. PM R 2024; 16:14-24. [PMID: 37162022 PMCID: PMC10786620 DOI: 10.1002/pmrj.12994] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2022] [Revised: 03/20/2023] [Accepted: 04/26/2023] [Indexed: 05/11/2023]
Abstract
INTRODUCTION Over-prescription of opioids has diminished in recent years; however, certain populations remain at high risk. There is a dearth of research evaluating prescription rates using specific multimorbidity patterns. OBJECTIVE To identify distinct clinical profiles associated with opioid prescription and evaluate their relative odds of receiving long-term opioid therapy. DESIGN Retrospective analysis of the complete military electronic health record. We assessed demographics and 26 physiological, psychological, and pain conditions present during initial opioid prescription. Latent class analysis (LCA) identified unique clinical profiles using diagnostic data. Logistic regression measured the odds of these classes receiving long-term opioid therapy. SETTING All electronic health data under the TRICARE network. PARTICIPANTS All servicemembers on active duty during fiscal years 2016 through 2019 who filled at least one opioid prescription. MAIN OUTCOME MEASURES Number and qualitative characteristics of LCA classes; odds ratios (ORs) from logistic regression. We hypothesized that LCA classes characterized by high-risk contraindications would have significantly higher odds of long-term opioid therapy. RESULTS A total of N = 714,446 active duty servicemembers were prescribed an opioid during the study window, with 12,940 (1.8%) receiving long-term opioid therapy. LCA identified five classes: Relatively Healthy (82%); Musculoskeletal Acute Pain and Substance Use Disorders (6%); High Pain, Low Mental Health Burden (9%); Low Pain, High Mental Health Burden (2%), and Multisystem Multimorbid (1%). Logistic regression found that, compared to the Relatively Healthy reference, the Multisystem Multimorbid class, characterized by multiple opioid contraindications, had the highest odds of receiving long-term opioid therapy (OR = 9.24; p < .001; 95% confidence interval [CI]: 8.56, 9.98). CONCLUSION Analyses demonstrated that classes with greater multimorbidity at the time of prescription, particularly co-occurring psychiatric and pain disorders, had higher likelihood of long-term opioid therapy. Overall, this study helps identify patients most at risk for long-term opioid therapy and has implications for health care policy and patient care.
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Affiliation(s)
- Steven Dufour
- Department of Medical and Clinical Psychology, Uniformed Services University of the Health Sciences, Bethesda, MD
- Naval Medical Center Portsmouth, Portsmouth, VA
| | - Amanda Banaag
- The Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., Bethesda, MD
| | - Andrew J. Schoenfeld
- Department of Orthopaedic Surgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA
| | - Rachel Sayko Adams
- Boston University School of Public Health, Department of Health Law, Policy and Management, Boston, MA
- Veterans Health Administration, Rocky Mountain Mental Illness Research Education and Clinical Center, Aurora, CO
| | - Tracey Perez Koehlmoos
- Center for Health Services Research, Uniformed Services University of the Health Sciences, Bethesda, Maryland
| | - Joshua C. Gray
- Department of Medical and Clinical Psychology, Uniformed Services University of the Health Sciences, Bethesda, MD
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Roger VL, Banaag A, Korona-Bailey J, Wiley TMP, Turner CE, Haigney MC, Koehlmoos TP. Prevalence of Heart Failure Stages in a Universal Health Care System: The Military Health System Experience. Am J Med 2023; 136:1079-1086.e1. [PMID: 37481019 PMCID: PMC10592056 DOI: 10.1016/j.amjmed.2023.07.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2023] [Revised: 07/03/2023] [Accepted: 07/05/2023] [Indexed: 07/24/2023]
Abstract
BACKGROUND Morbidity and mortality related to heart failure are increasing and disparities are widening. These alarming trends, often confounded by access to care, are poorly understood. This study evaluates the prevalence of all stages of heart failure by race and socioeconomic status in an environment with no access barrier to care. METHODS We conducted a cross-sectional observational study of adult beneficiaries aged 18 to 64 years of the Military Health System (MHS), a model for universal health care for fiscal years 2018-2019. We calculated prevalence of preclinical (stages A/B) or clinical (stages C/D) heart failure stages as defined by professional guidelines. Results were analyzed by age, race, and socioeconomic status (using military rank as a proxy). RESULTS Among 5,440,761 MHS beneficiaries aged 18 to 64 years, prevalence of preclinical and clinical heart failure was 18.1% and 2.5%, respectively. Persons with preclinical heart failure were middle aged, with similar proportions of men and women, while those with heart failure were older, mainly men. After multivariable adjustment, male sex (1.35 odds ratio [OR] [preclinical]; 1.95 OR [clinical]), Black race (1.64 OR [preclinical]; 1.88 OR [clinical]) and lower socioeconomic status were significantly associated with large increases in the prevalence of all stages of heart failure. CONCLUSION All stages of heart failure are highly prevalent among MHS beneficiaries of working age and, in an environment with no access barrier to care, there are striking disparities by race and socioeconomic status. The high prevalence of preclinical heart failure, particularly notable among Black beneficiaries, delineates a critical time window for prevention.
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Affiliation(s)
- Véronique L Roger
- Division of Intramural Research, National Heart Lung and Blood Institute, National Institutes of Health, Bethesda, Md.
| | - Amanda Banaag
- Uniformed Services University of the Health Science, Bethesda, Md; Henry M. Jackson Foundation for the Advancement of Military Medicine Inc, Bethesda, Md
| | - Jessica Korona-Bailey
- Uniformed Services University of the Health Science, Bethesda, Md; Henry M. Jackson Foundation for the Advancement of Military Medicine Inc, Bethesda, Md
| | - Tiffany M Powell Wiley
- Division of Intramural Research, National Heart Lung and Blood Institute, National Institutes of Health, Bethesda, Md; National Institute on Minority Health and Health Disparities, National Institutes of Health, Bethesda, Md
| | - Clesson E Turner
- National Human Genome Research Institute, National Institutes of Health, Bethesda, Md
| | - Mark C Haigney
- Military Cardiovascular Outcomes Research, Cardiology Division, Uniformed Services University, Bethesda Md
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Sayegh MA, Banaag A, Korona-Bailey J, Madsen C, Frank A, Koehlmoos TP. The burden of vestibular disorders among military health system (MHS) beneficiaries, fiscal years 2018-2019. PLoS One 2023; 18:e0286798. [PMID: 37856452 PMCID: PMC10586620 DOI: 10.1371/journal.pone.0286798] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2022] [Accepted: 05/23/2023] [Indexed: 10/21/2023] Open
Abstract
INTRODUCTION Vestibular disorders affect an estimated 33 million adults and 3.5 million children and adolescents in the United States. Previous research relying on self-reported symptoms versus actual diagnosis has limited the ability to provide prevalence estimates for specific vestibular disorders at the population level. This study seeks to describe the burden of vestibular disorders among children and working-age adult beneficiaries in the Military Health System (MHS). MATERIALS AND METHODS Using the MHS Data Repository (MDR), we conducted a cross-sectional study of all TRICARE Prime and Plus MHS beneficiaries aged 0 to 64 years from fiscal years (FY) 2018 to 2019. Study analyses included descriptive statistics of patient demographics and assessing the prevalence of vestibular disorders in pediatric and working-age adult beneficiaries. RESULTS Of the 5,541,932 TRICARE Prime/Prime Plus MHS beneficiaries, 52,878 (0.95%) had a diagnosis of vestibular disorder during fiscal years 2018 to 2019, of which 1,359 were pediatric and adolescents (aged 0 to 17 years) and 51,519 were working-age adults (18 to 64 years). Vertigo was the most common diagnosis in both age-group populations (11.46 per 1,000 working-age adults; 0.52 per 1,000 children and adolescents), with benign vertigo being the most prevalent of the three diagnoses and occurring at a seven times higher rate in adults versus pediatric and adolescents. CONCLUSIONS This study demonstrates the effectiveness of using medical claims data to estimate prevalence compared to self-reported survey data and supports prevalence estimates of vestibular disease in <1% of children overall, but indicate much higher prevalence for adolescents.
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Affiliation(s)
- M. Aaron Sayegh
- Center for Health Services Research, Department of Preventive Medicine and Biostatistics, Uniformed Services University of the Health Sciences, Bethesda, Maryland, United States of America
- The Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., Bethesda, Maryland, United States of America
| | - Amanda Banaag
- Center for Health Services Research, Department of Preventive Medicine and Biostatistics, Uniformed Services University of the Health Sciences, Bethesda, Maryland, United States of America
- The Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., Bethesda, Maryland, United States of America
| | - Jessica Korona-Bailey
- Center for Health Services Research, Department of Preventive Medicine and Biostatistics, Uniformed Services University of the Health Sciences, Bethesda, Maryland, United States of America
- The Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., Bethesda, Maryland, United States of America
| | - Cathaleen Madsen
- Center for Health Services Research, Department of Preventive Medicine and Biostatistics, Uniformed Services University of the Health Sciences, Bethesda, Maryland, United States of America
- The Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., Bethesda, Maryland, United States of America
| | - Amanda Frank
- Department of Defense, Hearing Center of Excellence, Defense Health Agency, Joint Base San Antonio, San Antonio, Texas, United States of America
- zCore Business Solutions, Inc., Round Rock, Texas, United States of America
| | - Tracey Pérez Koehlmoos
- Center for Health Services Research, Department of Preventive Medicine and Biostatistics, Uniformed Services University of the Health Sciences, Bethesda, Maryland, United States of America
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Characteristics of drinking episodes associated with simultaneous alcohol and cannabis use among underage drinkers in the United States. Addict Behav 2023; 136:107501. [PMID: 36181745 DOI: 10.1016/j.addbeh.2022.107501] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2022] [Revised: 08/27/2022] [Accepted: 09/19/2022] [Indexed: 02/03/2023]
Abstract
BACKGROUND Simultaneous alcohol and cannabis (SAC) use is associated with more negative consequences than independent use of alcohol or cannabis. Contextual characteristics of drinking episodes are associated with the quantity of alcohol consumed and related risk. This study examined whether drinking contexts may also be associated with SAC use. METHODS National Survey on Drug Use and Health (NSDUH) 2010-2019 data from past 30-day drinkers aged 12-20 (n = 39,456) were used. A weighted multivariable logistic regression model examined associations between contextual characteristics (alcohol source, number of people, drinking location) and SAC use during their most recent drinking occasion. Models adjusted for survey year, heavy episodic drinking, age, sex, race/ethnicity, student status, and metropolitan area status. RESULTS More than one-in-five drinkers reported SAC use. Compared to getting alcohol from parents/family, those who took it from a home (OR = 1.51,95 %CI = 1.24,1.84), got it for free another way (OR = 2.30,95 %CI = 2.05,2.59), paid someone else for it (OR = 2.83,95 %CI = 2.46,3.25), or purchased it themselves (OR = 3.12,95 %CI = 2.66,3.67) had higher odds of SAC use. Compared to drinking alone, drinking with more than one person was associated with higher odds of SAC use (OR = 1.36,95 %CI = 1.12,1.66). Compared to drinking in their home, drinking in a bar (OR = 0.51,95 %CI = 0.41,0.64) had lower odds of SAC use, whereas drinking in someone else's home (OR = 1.12,95 %CI = 1.02,1.22), a car (OR = 1.36,95 %CI = 1.04,1.77), or multiple locations (OR = 1.29,95 %CI = 1.09,1.53) had higher odds of SAC use. CONCLUSIONS Findings suggest that alcohol-related contextual characteristics are associated with SAC use among underage drinkers. Laws addressing underage alcohol consumption, including social host liability and sales to minors laws, may also decrease simultaneous cannabis use.
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Kikuchi JY, Banaag A, Koehlmoos TP. Antibiotic Prescribing Patterns and Guideline Concordance for Uncomplicated Urinary Tract Infections Among Adult Women in the US Military Health System. JAMA Netw Open 2022; 5:e2225730. [PMID: 35925603 PMCID: PMC9353594 DOI: 10.1001/jamanetworkopen.2022.25730] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
IMPORTANCE Urinary tract infections (UTIs) are one of the most commonly diagnosed infections, and prior studies have reported discordance in antibiotic treatment with the Infectious Diseases Society of America (IDSA) guidelines. OBJECTIVE To assess IDSA guideline concordance rates for women with uncomplicated UTIs treated with antibiotics, and compare concordance rates between different specialty field. DESIGN, SETTING, AND PARTICIPANTS Retrospective cross-sectional study of health care claims data from the US Military Health System Data Repository, which contains comprehensive health care encounter and claims data for all military beneficiaries. Participants were adult women between the ages of 18 to 50 years with uncomplicated UTIs from October 1, 2017, to September 30, 2019. Data extraction and analysis were performed in 2022. Patients with diagnosis of UTI in the preceding 6 months, current pregnancy, history of pyelonephritis, history of diabetes, history of organ transplant, history of human immunodeficiency virus, immunosuppression, renal insufficiency, urinary tract abnormalities, or history of urologic procedures were excluded. EXPOSURES Antibiotic treatment for uncomplicated UTIs. Only antibiotics received within 1 day after the diagnosis were analyzed. The IDSA recommends the following antibiotics as first-line therapy: nitrofurantoin, trimethoprim-sulfamethoxazole, fosfomycin, pivmecillinam. MAIN OUTCOMES AND MEASURES The IDSA guideline concordance rates were calculated as the number of patients receiving first-line antibiotic therapy divided by the total number of cases for uncomplicated UTIs. RESULTS A total of 46 793 adult women (67.3% [31 475 of 46 793] aged 18-34 years; 38.2% [31 475 of 46 793] of White race) were diagnosed with uncomplicated UTIs with 91.0% receiving guideline-concordant antibiotic treatment. In comparison with obstetrics and gynecology, IDSA guideline-concordant treatment was more likely in internal medicine (adjusted odds ratio [aOR], 2.87; 95% CI, 2.73-3.03), family medicine (aOR, 1.81; 95% CI, 1.76-1.87), surgery (aOR, 1.51; 95% CI, 1.36-1.67), and emergency medicine (aOR, 1.36; 95% CI, 1.32-1.39) and less likely in urology (aOR, 0.40; 95% CI, 0.38-0.43). Compared with direct military care, private sector care had lower concordance rates (aOR, 0.63; 95% CI, 0.62-0.64). CONCLUSIONS AND RELEVANCE In this cross-sectional study of antibiotic treatments for uncomplicated UTIs in a universally insured population, the IDSA guideline-concordance rate was high at 91.0% with higher rates in direct military care compared with private sector care. There were higher rates in general medical specialties, surgery, and emergency medicine and lower rates in urology and obstetrics and gynecology. These results further enhance the literature on current antibiotic prescribing practices for uncomplicated UTIs in adult women.
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Affiliation(s)
- Jacqueline Y. Kikuchi
- Department of Gynecology and Obstetrics, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Amanda Banaag
- Department of Preventative Medicine and Biostatistics, Uniformed Services University, Bethesda, Maryland
- Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc, Bethesda, Maryland
| | - Tracey P. Koehlmoos
- Department of Preventative Medicine and Biostatistics, Uniformed Services University, Bethesda, Maryland
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Ashbrook M, Cheng V, Sandhu K, Matsuo K, Schellenberg M, Inaba K, Matsushima K. Management of Complicated Appendicitis During Pregnancy in the US. JAMA Netw Open 2022; 5:e227555. [PMID: 35426921 PMCID: PMC9012961 DOI: 10.1001/jamanetworkopen.2022.7555] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
IMPORTANCE Data are sparse regarding the optimal treatment for complicated appendicitis during pregnancy. OBJECTIVE To compare nonoperative and operative management in complicated appendicitis during pregnancy. DESIGN, SETTING, AND PARTICIPANTS This cohort study was conducted using National Inpatient Sample data from between January 2003 and September 2015. This database approximates a 20% stratified sample of US inpatient hospital discharges. Included individuals were pregnant women discharged with the diagnosis of complicated appendicitis. Data were analyzed from February 2020 through February 2022. EXPOSURES Study patients were categorized into 3 groups: those with successful nonoperative management, failed nonoperative management with delayed operation, or immediate operation for complicated appendicitis. MAIN OUTCOMES AND MEASURES Clinical outcomes, including maternal infectious complications and perinatal complications, hospital length of stay, and total hospital charges. RESULTS Among 8087 pregnant women with complicated appendicitis (median [IQR] age, 27 [22-32] years), nonoperative management of complicated appendicitis was successful among 954 patients (11.8%) and failed among 2646 patients (32.7%), who underwent delayed operation; 4487 patients (55.5%) underwent immediate operation. In multivariate analysis, successful nonoperative management was associated with higher odds of amniotic infection (odds ratio [OR], 4.35; 95% CI, 2.22-8.53; P < .001) and sepsis (OR, 1.52; 95% CI, 1.10-2.11; P = .01) compared with immediate operation, while there was no significant difference in preterm delivery, preterm labor, or abortion. However, failed nonoperative management that required delayed operation was associated with higher odds of preterm delivery, preterm labor, or abortion compared with immediate operation (OR, 1.45; 95% CI, 1.24-1.68; P < .001). Immediate operation was associated with decreased hospital charges compared with nonoperative management that was successful (regression coefficient [RC], 0.09; 95% CI, 0.07-0.11; P < .001) and that failed (RC, 0.12; 95% CI: 0.11-0.14; P < .001). In subgroup multivariate logistic regression analysis, each day in delay to surgery was associated with an increase in odds of preterm delivery, preterm labor, or abortion by 23% (OR, 1.23; 95% CI, 1.18-1.29; P < .001). CONCLUSIONS AND RELEVANCE This study found that immediate operation for complicated appendicitis in pregnant women was associated with lower odds of maternal infectious complications without higher odds of perinatal or other maternal complications compared with successful nonoperative management. Failed nonoperative management was associated with worse clinical outcomes.
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Affiliation(s)
- Matthew Ashbrook
- Division of Acute Care Surgery, Department of Surgery, University of Southern California, Los Angeles
| | - Vincent Cheng
- Division of Acute Care Surgery, Department of Surgery, University of Southern California, Los Angeles
| | - Kulmeet Sandhu
- Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, California
| | - Koji Matsuo
- Department of Obstetrics and Gynecology, University of Southern California, Los Angeles
| | - Morgan Schellenberg
- Division of Acute Care Surgery, Department of Surgery, University of Southern California, Los Angeles
| | - Kenji Inaba
- Division of Acute Care Surgery, Department of Surgery, University of Southern California, Los Angeles
| | - Kazuhide Matsushima
- Division of Acute Care Surgery, Department of Surgery, University of Southern California, Los Angeles
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Mohammed H, Huang Y, Memtsoudis S, Parks M, Huang Y, Ma Y. Utilization of machine learning methods for predicting surgical outcomes after total knee arthroplasty. PLoS One 2022; 17:e0263897. [PMID: 35316270 PMCID: PMC8939835 DOI: 10.1371/journal.pone.0263897] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2021] [Accepted: 01/29/2022] [Indexed: 11/20/2022] Open
Abstract
Background Predictive models could help clinicians identify risk factors that cause adverse events after total knee arthroplasty (TKA), allowing for appropriate preoperative preventive interventions and allocation of resources. Methods The National Inpatient Sample datasets from 2010–2014 were used to build Logistic Regression (LR), Gradient Boosting Method (GBM), Random Forest (RF), and Artificial Neural Network (ANN) predictive models for three clinically relevant outcomes after TKA—disposition at discharge, any post-surgical complications, and blood transfusion. Model performance was evaluated using the Brier scores as calibration measures, and area under the ROC curve (AUC) and F1 scores as discrimination measures. Results GBM-based predictive models were observed to have better calibration and discrimination than the other models; thus, indicating comparatively better overall performance. The Brier scores for GBM models predicting the outcomes under investigation ranged from 0.09–0.14, AUCs ranged from 79–87%, and F1-scores ranged from 41–73%. Variable importance analysis for GBM models revealed that admission month, patient location, and patient’s income level were significant predictors for all the outcomes. Additionally, any post-surgical complications and blood transfusions were significantly predicted by deficiency anemias, and discharge disposition by length of stay and age groups. Notably, any post-surgical complications were also significantly predicted by the patient undergoing blood transfusion. Conclusions The predictive abilities of the ML models were successfully demonstrated using data from the National Inpatient Sample (NIS), indicating a wide range of clinical applications for obtaining accurate prognoses of complications following orthopedic surgical procedures.
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Affiliation(s)
- Hina Mohammed
- Milken Institute School of Public Health, The George Washington University, Washington, DC, United States of America
- Syapse Inc, Palo Alto, California, United States of America
| | - Yihe Huang
- Milken Institute School of Public Health, The George Washington University, Washington, DC, United States of America
| | - Stavros Memtsoudis
- Hospital for Special Surgery, New York City, New York, United States of America
- Weill Cornell Medical College, Cornell University, New York City, New York, United States of America
| | - Michael Parks
- Hospital for Special Surgery, New York City, New York, United States of America
- Weill Cornell Medical College, Cornell University, New York City, New York, United States of America
| | - Yuxiao Huang
- Columbian College of Arts & Sciences, The George Washington University, Washington, DC, United States of America
| | - Yan Ma
- Milken Institute School of Public Health, The George Washington University, Washington, DC, United States of America
- * E-mail:
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Missing Data Imputation – A Survey. INTERNATIONAL JOURNAL OF DECISION SUPPORT SYSTEM TECHNOLOGY 2022. [DOI: 10.4018/ijdsst.292446] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Many real world datasets may contain missing values for various reasons. These incomplete datasets can pose severe issues to the underlying machine learning algorithms and decision support systems. It may result in high computational cost, skewed output and invalid deductions. Various solutions exist to mitigate this issue; the most popular strategy is to estimate the missing values by applying inferential techniques such as linear regression, decision trees or Bayesian inference. In this paper, the missing data problem is discussed in detail with a comprehensive review of the approaches to tackle it. The paper concludes with a discussion on the effectiveness of three imputation methods namely, imputation based on Multiple Linear Regression (MLR), Predictive Mean Matching (PMM) and Classification And Regression Tree (CART) in the context of subspace clustering. The experimental results obtained on real benchmark datasets and high-dimensional synthetic datasets highlight that, MLR based imputation method is more efficient on high-dimensional incomplete datasets.
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Mantey DS, Dixon S, Araya A, Montgomery L. The association between age of initiation and current blunt use among adults: Findings from the national survey on drug use and health, 2014-2019. Drug Alcohol Depend 2022; 230:109191. [PMID: 34890925 DOI: 10.1016/j.drugalcdep.2021.109191] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2021] [Revised: 11/08/2021] [Accepted: 11/10/2021] [Indexed: 11/03/2022]
Abstract
BACKGROUND Initiating cannabis use at a young age has been linked to problematic and continued cannabis use in adulthood. Given that approximately 1 in 3 adult cannabis smokers report blunt use, it is important to determine if and how age of blunt initiation is associated with current blunt use among adult blunt smokers. METHODS This study uses cross-sectional pooled data from the 2014-2019 National Survey on Drug Use and Health (NSDUH) to examine the association between age of blunt initiation and current blunt use among 62,020 adults who reported lifetime blunt use. RESULTS Among lifetime blunt smokers, 51.4% initiated blunt use at 18 years or older, 42.1% initiated blunt use at 14-17 years old and 6.5% initiated blunt use at 13 years or younger. Multivariable logistic regression models revealed that odds of past 12-month (aOR: 1.58; 95% CI: 1.45 - 1.72), past 30-day (aOR: 2.58; 95% CI: 2.37 - 2.80) and daily (aOR: 3.17; 95% CI: 2.61 - 3.86) blunt use were greater among adults who initiated blunt use at 13 years of age or younger relative to those who initiated blunt use at 18 years of age or older, controlling for covariates. CONCLUSIONS Early onset of blunt use among adolescents is associated with current blunt use in adulthood among lifetime blunt users. Given the adverse health effects associated with blunt use and the prevalence of adult cannabis users who report blunt use, cannabis interventions and policies should be expanded to target blunt use among early initiators.
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Affiliation(s)
- Dale S Mantey
- Health Promotion and Behavioral Science, University of Texas Health Science Center at Houston, 1616 Guadalupe St., Suite 6.300, Austin, TX 77030, USA.
| | - Shapree Dixon
- Department of Psychiatry and Behavioral Neuroscience, University of Cincinnati College of Medicine, 3131 Harvey Avenue, Cincinnati, OH 45229, USA
| | - Abraham Araya
- Department of Psychiatry and Behavioral Neuroscience, University of Cincinnati College of Medicine, 3131 Harvey Avenue, Cincinnati, OH 45229, USA
| | - LaTrice Montgomery
- Department of Psychiatry and Behavioral Neuroscience, University of Cincinnati College of Medicine, 3131 Harvey Avenue, Cincinnati, OH 45229, USA; Center for Addiction Research, University of Cincinnati College of Medicine, 3230 Eden Avenue, Cincinnati, OH 45267, USA
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Das S, Mukhopadhyay I. TiMEG: an integrative statistical method for partially missing multi-omics data. Sci Rep 2021; 11:24077. [PMID: 34911979 PMCID: PMC8674330 DOI: 10.1038/s41598-021-03034-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2021] [Accepted: 11/24/2021] [Indexed: 11/25/2022] Open
Abstract
Multi-omics data integration is widely used to understand the genetic architecture of disease. In multi-omics association analysis, data collected on multiple omics for the same set of individuals are immensely important for biomarker identification. But when the sample size of such data is limited, the presence of partially missing individual-level observations poses a major challenge in data integration. More often, genotype data are available for all individuals under study but gene expression and/or methylation information are missing for different subsets of those individuals. Here, we develop a statistical model TiMEG, for the identification of disease-associated biomarkers in a case-control paradigm by integrating the above-mentioned data types, especially, in presence of missing omics data. Based on a likelihood approach, TiMEG exploits the inter-relationship among multiple omics data to capture weaker signals, that remain unidentified in single-omic analysis or common imputation-based methods. Its application on a real tuberous sclerosis dataset identified functionally relevant genes in the disease pathway.
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Affiliation(s)
- Sarmistha Das
- Human Genetics Unit, Indian Statistical Institute, Kolkata, 700108, India
- Department of Biostatistics, St. Jude Children's Research Hospital, Memphis, 38105, USA
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Koehlmoos TP, Korona-Bailey J, Janvrin ML, Madsen C. Racial Disparities in the Military Health System: A Framework Synthesis. Mil Med 2021; 187:e1114-e1121. [PMID: 34910808 DOI: 10.1093/milmed/usab506] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2021] [Revised: 10/25/2021] [Accepted: 12/11/2021] [Indexed: 11/14/2022] Open
Abstract
INTRODUCTION Racial disparities in health care are a well-documented phenomenon in the USA. Universal insurance has been suggested as a solution to mitigate these disparities. We examined race-based disparities in the Military Health System (MHS) by constructing and analyzing a framework of existing studies that measured disparities between direct care (care provided by military treatment facilities) and private sector care (care provided by civilian health care facilities). MATERIALS AND METHODS We conducted a framework synthesis on 77 manuscripts published in partnership with the Comparative Effectiveness and Provider-Induced Demand Collaboration Project that use MHS electronic health record data to present an overview of racial disparities assessed for multiple treatment interventions in a nationally representative, universally insured population. RESULTS We identified 32 studies assessing racial disparities in areas of surgery, trauma, opioid prescription and usage, women's health, and others. Racial disparities were mitigated in postoperative complications, trauma care, and cancer screenings but persisted in diabetes readmissions, opioid usage, and minimally invasive women's health procedures. CONCLUSION Universal coverage mitigates many, but not all, racial disparities in health care. An examination of a broader range of interventions, a closer look at variation in care provided by civilian facilities, and a look at the quality of care by race provide further opportunities for research.
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Affiliation(s)
- Tracey Pérez Koehlmoos
- Center for Health Services Research, Uniformed Services University, Bethesda, MD 20814, USA
| | - Jessica Korona-Bailey
- Center for Health Services Research, Uniformed Services University, Bethesda, MD 20814, USA.,Henry M. Jackson Foundation, Bethesda, MD 20817, USA
| | - Miranda Lynn Janvrin
- Center for Health Services Research, Uniformed Services University, Bethesda, MD 20814, USA.,Henry M. Jackson Foundation, Bethesda, MD 20817, USA
| | - Cathaleen Madsen
- Center for Health Services Research, Uniformed Services University, Bethesda, MD 20814, USA.,Henry M. Jackson Foundation, Bethesda, MD 20817, USA
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Broquetas T, Herruzo-Pino P, Mariño Z, Naranjo D, Vergara M, Morillas RM, Forns X, Carrión JA. Elastography is unable to exclude cirrhosis after sustained virological response in HCV-infected patients with advanced chronic liver disease. Liver Int 2021; 41:2733-2746. [PMID: 34525253 DOI: 10.1111/liv.15058] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2020] [Revised: 08/23/2021] [Accepted: 09/01/2021] [Indexed: 12/15/2022]
Abstract
BACKGROUND Liver fibrosis and transient elastography (TE) correlation in hepatitis C virus (HCV)-infected patients with compensated advanced chronic liver disease (cACLD) after the sustained virological response (SVR) is unknown. AIMS To evaluate TE accuracy at identifying cirrhosis 3 years after HCV-eradication. METHODS Prospective, multi-centric study including HCV-cACLD patients before direct-acting antivirals (DAA). Diagnostic accuracy of TE (area under ROC, AUROC) to identify cirrhosis 3 years after SVR was evaluated. RESULTS Among 746 HCV-infected patients (95.4% with TE ≥10 kPa), 76 (10.2%) underwent a liver biopsy 3 years after SVR. Before treatment, 46 (63%) showed a TE>15 kPa. The TE before DAA was the best variable for predicting cirrhosis (METAVIR, F4) after SVR (AUROC = 0.79). Liver function parameters, serological non-invasive tests (APRI and FIB-4), and TE values improved after SVR. However, liver biopsy 3 years after HCV elimination (median time = 38.4 months) showed cirrhosis in 41 (53.9%). Multivariate analysis (OR (95% CI), P) showed that HCV-genotype 3 (20.81 (2.12-201.47), .009), and TE before treatment (1.21 (1.09-1.34), <.001) were the only variables associated with cirrhosis after SVR. However, the accuracy of TE after SVR was poor (AUROC = 0.75) and 6 (27.3%) out of 22 patients with a TE <8 kPa had cirrhosis. Similar results were found with APRI and FIB-4 scores. CONCLUSIONS Cirrhosis is present, 3 years after SVR, in more than half of HCV-cACLD patients even with the normalisation of liver function parameters, serological non-invasive tests and TE values. The low diagnostic accuracy of non-invasive methods after SVR reinforces the need for long-term surveillance.
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Affiliation(s)
- Teresa Broquetas
- Liver Section, Gastroenterology Department, Hospital del Mar, Barcelona, Spain.,Universitat Autònoma de Barcelona (UAB), Departament de Medicina de la UAB, Barcelona, Spain
| | - Paula Herruzo-Pino
- Universitat Autònoma de Barcelona (UAB), Departament de Medicina de la UAB, Barcelona, Spain
| | - Zoe Mariño
- Liver Unit, Hospital Clínic de Barcelona, Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), IDIBAPS, University of Barcelona, Barcelona, Spain
| | - Dolores Naranjo
- Gastrointestinal and Hepatobiliary Pathology Section, Department of Pathology, Hospital del Mar, Barcelona, Spain
| | - Mercedes Vergara
- Liver Unit, Digestive Disease Department, Parc Taulí Sabadell Hospital Universitari, Institut d'Investigació i Innovació Parc Taulí I3PT, Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Rosa Mª Morillas
- Hepatology Department, Hospital Germans Trias i Pujol, Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Badalona, Spain
| | - Xavier Forns
- Liver Unit, Hospital Clínic de Barcelona, Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), IDIBAPS, University of Barcelona, Barcelona, Spain
| | - José A Carrión
- Liver Section, Gastroenterology Department, Hospital del Mar, Barcelona, Spain.,Universitat Autònoma de Barcelona (UAB), Departament de Medicina de la UAB, Barcelona, Spain
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Mantey DS, Chido-Amajuoyi OG, Omega-Njemnobi O, Montgomery L. Cigarette smoking frequency, quantity, dependence, and quit intentions during adolescence: Comparison of menthol and non-menthol smokers (National Youth Tobacco Survey 2017-2020). Addict Behav 2021; 121:106986. [PMID: 34087763 PMCID: PMC8244158 DOI: 10.1016/j.addbeh.2021.106986] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2021] [Revised: 04/15/2021] [Accepted: 05/12/2021] [Indexed: 11/27/2022]
Abstract
BACKGROUND Use of menthol cigarettes is linked to sustained cigarette smoking adults. However, the relationship between menthol and smoking profile has not been thoroughly explored in adolescent cigarette smokers. This study examines the relationship between use of menthol cigarette and smoking frequency (i.e., days per month), quantity (i.e., cigarettes per day), quit intentions, and nicotine dependence (i.e., craving tobacco; use within 30 min of waking). METHODS We pooled four years (2017-2020) of cross-sectional data from the National Youth Tobacco Survey. Participants were 2699 adolescent, past 30-day cigarette smokers. Multinomial logistic regression models examined the relationship between menthol and cigarette smoking frequency and quantity. Logistic regressions examined the relationship between menthol and intentions to quit smoking and nicotine dependence. Models controlled for socio-demographics and other tobacco use. RESULTS Menthol cigarette smokers had greater risk of smoking 20-30 days per month relative to 1-5 days per month (RRR: 1.90; 95% CI: 1.41 - 2.54) and greater risk of smoking 11+ cigarettes per day relative to 1 or less cigarettes per day (RRR: 1.35; 95% CI: 1.01 - 1.80), adjusting for covariates. Menthol cigarette smokers had lower odds of intentions to quit smoking (Adj OR: 0.70; 95% CI: 0.58 - 0.84) but great odds of craving tobacco (OR: 1.47; 95% CI: 1.20 - 1.81) and using tobacco within 30 minutes of waking (OR: 1.63; 95% CI: 1.29 - 2.05), adjusting for covariates CONCLUSION: Findings suggest the relationship between menthol and cigarette smoking profile (i.e., frequency, quantity, quit intentions) is different for youth than that of adults. This study adds adolescent-specific evidence to existing research that suggests menthol reinforces sustained cigarette smoking among youth.
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Affiliation(s)
- Dale S Mantey
- Department of Health Promotion and Behavioral Science, University of Texas School of Public Health, United States.
| | - Onyema Greg Chido-Amajuoyi
- Department of Epidemiology, The University of Texas MD Anderson Cancer Center, Houston, TX, United States; Division of Cancer Prevention and Population Sciences, The University of Texas MD Anderson Cancer Center, United States
| | - Onyinye Omega-Njemnobi
- Department of Health Promotion and Behavioral Science, University of Texas School of Public Health, United States
| | - LaTrice Montgomery
- Department of Psychiatry and Behavioral Neuroscience, Addiction Sciences Division, University of Cincinnati College of Medicine, United States
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Martin R, Banaag A, Riggs DS, Koehlmoos TP. Minority Adolescent Mental Health Diagnosis Differences in a National Sample. Mil Med 2021; 187:e969-e977. [PMID: 34387672 DOI: 10.1093/milmed/usab326] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2021] [Revised: 04/16/2021] [Accepted: 07/28/2021] [Indexed: 11/14/2022] Open
Abstract
INTRODUCTION Mental health disparities and differences have been identified amongst all age groups, including adolescents. However, there is a lack of research regarding adolescents within the Military Health System (MHS). The MHS is a universal health care system for military personnel and their dependents. Research has indicated that the MHS removes many of the barriers that contribute to health disparities. Additional investigations with this population would greatly contribute to our understanding of disparities and health services delivery without the barrier of access to care. MATERIALS AND METHODS This study analyzed the diagnostic trends of anxiety, depression, and impulse control disorders and differences within a national sample of adolescents of active-duty military parents. The study utilized 2006 to 2014 data in the MHS Data Repository for adolescents ages 13-18. The study identified 183,409 adolescents with at least one diagnosis. Multivariable logistic regressions were conducted to assess the differences and risks for anxiety, depression, and impulse control disorders in the identified sample. RESULTS When compared to White Americans, minority patients had a higher likelihood of being diagnosed with an impulse control disorder (odds ratio [OR] = 1.43; confidence interval [CI] 1.39-1.48) and a decreased likelihood of being diagnosed with a depressive disorder (OR = 0.98; CI 0.95-1.00) or anxiety disorder (OR = 0.80; CI 0.78-0.83). Further analyses examining the subgroups of minorities revealed that, when compared to White Americans, African American adolescents have a much higher likelihood of receiving a diagnosis of an impulse control disorder (OR = 1.66; CI 1.61-1.72) and a lower likelihood of receiving a diagnosis of a depressive disorder (OR = 0.93; CI 0.90-0.96) and an anxiety disorder (OR = 0.75; CI 0.72-0.77). CONCLUSION This study provides strong support for the existence of race-based differences in adolescent mental health diagnoses. Adolescents of military families are a special population with unique experiences and stressors and would benefit from future research focusing on qualitative investigations into additional factors mental health clinicians consider when making diagnoses, as well as further exploration into understanding how best to address this special population's mental health needs.
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Affiliation(s)
- Raquel Martin
- Department of Medical and Clinical Psychology, Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA
| | - Amanda Banaag
- Department of Preventive Medicine and Biostatistics, Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc, Bethesda, MD 20817, USA
| | - David S Riggs
- Department of Medical and Clinical Psychology, Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA
| | - Tracey P Koehlmoos
- Department of Medical and Clinical Psychology, Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA
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Timing of physical therapy for individuals with patellofemoral pain and the influence on healthcare use, costs and recurrence rates: an observational study. BMC Health Serv Res 2021; 21:751. [PMID: 34320969 PMCID: PMC8320186 DOI: 10.1186/s12913-021-06768-8] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2021] [Accepted: 07/12/2021] [Indexed: 12/05/2022] Open
Abstract
Background Early physical therapy has been shown to decrease downstream healthcare use, costs and recurrence rates in some musculoskeletal conditions, but it has not been investigated in individuals with patellofemoral pain. The purpose was to evaluate how the use and timing of physical therapy influenced downstream healthcare use, costs, and recurrence rates. Methods Seventy-four thousand four hundred eight individuals aged 18 to 50 diagnosed with patellofemoral pain between 2010 and 2011 in the Military Health System were categorized based on use and timing of physical therapy (first, early, or delayed). Healthcare use, costs, and recurrence rates were compared between the groups using descriptive statistics and a binary logit regression. Results The odds for receiving downstream healthcare use (i.e. imaging, prescription medications, and injections) were lowest in those who saw a physical therapist as the initial contact provider (physical therapy first), and highest in those who had delayed physical therapy (31–90 days after patellofemoral pain diagnosis). Knee-related costs for those receiving physical therapy were lowest in the physical therapy first group ($1,136, 95% CI $1,056, $1,217) and highest in the delayed physical therapy group ($2,283, 95% CI $2,192, $2,374). Recurrence rates were lowest in the physical therapy first group (AOR = 0.55, 95% CI 0.37, 0.79) and highest in the delayed physical therapy group (AOR = 1.78, 95% CI 1.36, 2.33). Conclusions For individuals with patellofemoral pain using physical therapy, timing is likely to influence outcomes. Healthcare use and costs and the odds of having a recurrence of knee pain were lower for patients who had physical therapy first or early compared to having delayed physical therapy.
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Young JL, Snodgrass SJ, Cleland JA, Rhon DI. The relationship between knee radiographs and the timing of physical therapy in individuals with patellofemoral pain. PM R 2021; 14:496-503. [PMID: 34288533 DOI: 10.1002/pmrj.12678] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2021] [Revised: 07/07/2021] [Accepted: 07/09/2021] [Indexed: 11/06/2022]
Abstract
BACKGROUND Routine knee radiographs are discouraged for individuals with non-traumatic knee pain, but they are often still ordered despite limited evidence for their value in guiding treatment choices. Radiograph utilization may delay the use of physical therapy, which has been associated with improved outcomes and lower long-term costs. OBJECTIVE To examine the relationship between obtaining knee radiographs for patients with patellofemoral pain (PFP) and the timing of physical therapy, and the association between ordering radiographs for patients who use physical therapy and the likelihood of knee pain recurrence. STUDY DESIGN Retrospective cohort. SETTING United States Military Health System civilian and military clinics. PATIENTS 23,332 individuals aged 18 to 50 diagnosed with PFP between 2010 and 2011 in the United States Military Health System who received physical therapy. INTERVENTIONS Physical therapy provided to individuals who did or did not receive an initial radiograph. MAIN OUTCOME MEASURES Timing of physical therapy and recurrence of knee pain were compared between groups (with and without initial radiographs). RESULTS If radiographs were used, the odds of initiating physical therapy (aOR = 0.78; 95% CI 0.64 to 0.94) within 30 days of the initial diagnosis were significantly lower. The mean days from diagnosis to initiating physical therapy was 12.1 (95% CI 9.1 to 16.1) if patients had radiographs versus 6.9 (95% CI 5.2 to 9.1) without. The odds of knee pain recurrence were no greater if radiographs were used (aOR = 1.01; 95% CI 0.83 to 1.22). CONCLUSIONS Receiving knee radiographs as part of initial care for PFP was associated with delayed initiation of physical therapy, but there was no association between early knee radiographs and recurrence of knee pain. Routine use of radiographs for PFP is not warranted, and can potentially delay appropriate treatment. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- Jodi L Young
- Doctor of Science in Physical Therapy, Bellin College, 3201 Eaton Rd., Green Bay, WI, USA.,Discipline of Physiotherapy, School of Health Sciences, The University of Newcastle, University Dr., Callaghan, NSW, Australia
| | - Suzanne J Snodgrass
- Discipline of Physiotherapy, School of Health Sciences, The University of Newcastle, University Dr., Callaghan, NSW, Australia
| | - Joshua A Cleland
- Doctor of Physical Therapy Program, Department of Public Health and Community Medicine, Tufts University School of Medicine, Boston, MA, USA
| | - Daniel I Rhon
- Discipline of Physiotherapy, School of Health Sciences, The University of Newcastle, University Dr., Callaghan, NSW, Australia.,TX, USA.,Physical Therapy Department, Baylor University, Stanley, TX, USA
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23
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Ranjit A, Andriotti T, Madsen C, Koehlmoos T, Staat B, Witkop C, Little SE, Robinson J. Does Universal Coverage Mitigate Racial Disparities in Potentially Avoidable Maternal Complications? Am J Perinatol 2021; 38:848-856. [PMID: 31986540 DOI: 10.1055/s-0040-1701195] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
OBJECTIVE Potentially avoidable maternity complications (PAMCs) have been validated as an indicator of access to quality prenatal care. African-American mothers have exhibited a higher incidence of PAMCs, which has been attributed to unequal health coverage. The objective of this study was to assess if racial disparities in the incidence of PAMCs exist in a universally insured population. STUDY DESIGN PAMCs in each racial group were compared relative to White mothers using multivariate logistic regression. Stratified subanalyses assessed for adjusted differences in the odds of PAMCs for each racial group within direct versus purchased care. RESULTS A total of 675,553 deliveries were included. Among them, 428,320 (63%) mothers were White, 112,170 (17%) African-American, 37,151 (6%) Asian/Pacific Islanders, and 97,912 (15%) others. African-American women (adjusted odds ratio [aOR]: 1.05, 95% CI: 1.02-1.08) were more likely to have PAMCs compared with White women, and Asian women (aOR: 0.92, 95% CI: 0.89-0.95) were significantly less likely to have PAMCs compared with White women. On stratified analysis according to the system of care, equal odds of PAMCs among African-American women compared with White women were realized within direct care (aOR: 1.03, 95% CI: 1.00-1.07), whereas slightly higher odds among African-American persisted in purchased (aOR: 1.05, 95% CI: 1.01-1.10). CONCLUSION Higher occurrence of PAMCs among minority women sponsored by a universal health coverage was mitigated compared with White women. Protocol-based care as in the direct care system may help overcome health disparities.
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Affiliation(s)
- Anju Ranjit
- Department of Obstetrics and Gynecology, Howard University Hospital, Washington, District of Columbia
| | - Tomas Andriotti
- Center for Surgery and Public Health, Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts
| | - Cathaleen Madsen
- Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., Bethesda, Maryland
| | - Tracey Koehlmoos
- Department of Preventive Medicine and Biostatistics, Uniformed Services University of the Health Sciences, Bethesda, Maryland
| | - Barton Staat
- Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., Bethesda, Maryland.,Department of Obstetrics and Gynecology, Uniformed Services University of the Health Sciences, Bethesda, Maryland
| | - Catherine Witkop
- Department of Obstetrics and Gynecology, Uniformed Services University of the Health Sciences, Bethesda, Maryland
| | - Sarah E Little
- Department of Obstetrics, Brigham and Women's Hospital, Boston, Massachusetts
| | - Julian Robinson
- Department of Obstetrics, Brigham and Women's Hospital, Boston, Massachusetts
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24
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Andriotti T, Ranjit A, Hamlin L, Koehlmoos T, Robinson JN, Lutgendorf MA. Psychiatric Conditions During Pregnancy and Postpartum in a Universally Insured American Population. Mil Med 2021; 187:e795-e801. [PMID: 33881522 DOI: 10.1093/milmed/usab154] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2020] [Revised: 02/16/2021] [Accepted: 04/14/2021] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Mental health conditions are common and can have significant effects during the perinatal period. Our objective was to determine the incidences and predictors of psychiatric conditions during pregnancy and postpartum among universally insured American women. MATERIAL AND METHODS This was an Institutional Review Board (IRB)-approved protocol using a retrospective cohort of 104,866 deliveries covered by TRICARE from 2005 to 2014. We used TRICARE claims data to identify pregnant women without current psychiatric conditions who developed new psychiatric condition(s) during pregnancy or postpartum compared with those who did not, as identified by International Classification of Diseases (ICD)-9 CM codes. Predictors of psychiatric conditions during pregnancy or postpartum were determined using stepwise logistic regression models. RESULTS A total of 104,866 women met the inclusion criteria; of these, 35% (n = 36,192) were diagnosed with a new psychiatric condition during pregnancy or within 1 year of delivery, 15% (n = 15,636) with a psychiatric condition during pregnancy, and 20% (n = 20,556) with a psychiatric condition within 1 year of delivery. We demonstrated that the African-American race (odds ratio [OR] 1.16, 95% CI 1.10-1.22), active duty status (OR 1.20, 95% CI 1.14-1.25), and severe maternal morbidity during delivery (OR 1.18, 95% CI 1.02-1.35) were significantly associated with the occurrence of a psychiatric condition within 1 year of delivery. For Asian women, there was a 28% higher odds of developing a psychiatric disorder during pregnancy (adjusted OR 1.28, 95% CI 1.17-1.40) compared with White women. Active duty women were twice as likely to be diagnosed with post-traumatic stress disorder (adjusted OR 2.31, 95% CI 1.83-2.90). CONCLUSION In a universally insured population, the incidences of psychiatric conditions in pregnancy and within a year of delivery were similar to the American population. Additionally, the development of psychiatric conditions in pregnancy and within a year of delivery may be associated with race, active duty status, and complicated births.
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Affiliation(s)
| | - Anju Ranjit
- Department of Obstetrics and Gynecology, Howard University, Washington, DC 20060, USA
| | - Lynette Hamlin
- Daniel K. Inouye Graduate School of Nursing, Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA
| | - Tracey Koehlmoos
- Daniel K. Inouye Graduate School of Nursing, Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA.,Department of Preventive Medicine and Biostatistics, Uniformed Services University, Bethesda, MD 20814, USA
| | - Julian N Robinson
- Department of Obstetrics, Brigham and Women's Hospital, Boston, MA 02115, USA
| | - Monica A Lutgendorf
- Department of Obstetrics and Gynecology, Naval Medical Center San Diego, San Diego, CA 92134, USA
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25
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Chen JA, Glass JE, Bensley KMK, Goldberg SB, Lehavot K, Williams EC. Racial/ethnic and gender differences in receipt of brief intervention among patients with unhealthy alcohol use in the U.S. Veterans Health Administration. J Subst Abuse Treat 2020; 119:108078. [PMID: 32736926 DOI: 10.1016/j.jsat.2020.108078] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2019] [Revised: 06/18/2020] [Accepted: 07/08/2020] [Indexed: 12/14/2022]
Abstract
OBJECTIVE Brief intervention (BI) for unhealthy alcohol use is a top prevention priority for adults in the U.S, but rates of BI receipt vary across patients. We examine BI receipt across race/ethnicity and gender in a national cohort of patients from the Department of Veterans Affairs (VA)-the largest U.S. integrated healthcare system and a leader in implementing preventive care for unhealthy alcohol use. METHODS Among 779,041 VA patients with documented race/ethnicity and gender who screened positive for unhealthy alcohol use (AUDIT-C score ≥ 5) between 10/1/09 and 5/30/13, we fit Poisson regression models to estimate the predicted prevalence of BI (EHR-documented advice to reduce or abstain from drinking) across race/ethnicity and gender. RESULTS Rates of BI were lowest among Black women (67%), Black men (68%), and Asian/Pacific Islander women (68%), and highest among white men (75%), Hispanic men (75%), and Asian/Pacific Islander men (75%). A significant race/ethnicity by gender interaction indicated that the associations between race/ethnicity and gender with BI depended on the other factor. Gender differences were largest among Asian/Pacific Islander patients and were nonsignificant among American Indian/Alaska Native patients. Adjustment for covariates not expected to be on the causal pathway (e.g., age, year of AUDIT-C screen) slightly attenuated but did not change the direction of results. CONCLUSIONS Receipt of BI for unhealthy alcohol use varied by race/ethnicity and gender, and the impact of one factor depended on the other. Black women, Black men, and Asian/Pacific Islander women had the lowest rates of receiving recommended alcohol-related care. We found these disparities in a healthcare system that has implemented universal alcohol screening and incentivized BI for all patients with unhealthy alcohol use, suggesting that reducing disparities in alcohol-related care may require targeted interventions.
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Affiliation(s)
- Jessica A Chen
- Health Services Research & Development (HSR&D), Seattle-Denver Center of Innovation for Veteran-Centered & Value-Driven Care, Veterans Affairs (VA) Puget Sound Health Care System, 1660 S. Columbian Way, S-152, Seattle, WA 98108, USA; Department of Psychiatry and Behavioral Sciences, University of Washington, 1959 NE Pacific St., Box 356560, Seattle, WA 98195-6560, USA.
| | - Joseph E Glass
- Department of Psychiatry and Behavioral Sciences, University of Washington, 1959 NE Pacific St., Box 356560, Seattle, WA 98195-6560, USA; Kaiser Permanente Washington Health Research Institute, 1730 Minor Ave, Seattle, WA 98101, USA; Department of Health Services, University of Washington, 1959 NE Pacific St., Box 357660, Seattle, WA 98195-7660, USA.
| | - Kara M K Bensley
- Alcohol Research Group, Public Health Institute, 6001 Shellmound St, Suite 450, Emeryville, CA 94608, USA; Department of Public Health, Bastyr University, 14500 Juanita Dr NE, Kenmore, WA 98028, USA.
| | - Simon B Goldberg
- Department of Counseling Psychology, University of Wisconsin - Madison, 335 Education Building, 1000 Bascom Mall, Madison, WI, 53706, USA.
| | - Keren Lehavot
- Health Services Research & Development (HSR&D), Seattle-Denver Center of Innovation for Veteran-Centered & Value-Driven Care, Veterans Affairs (VA) Puget Sound Health Care System, 1660 S. Columbian Way, S-152, Seattle, WA 98108, USA; Department of Psychiatry and Behavioral Sciences, University of Washington, 1959 NE Pacific St., Box 356560, Seattle, WA 98195-6560, USA; Department of Health Services, University of Washington, 1959 NE Pacific St., Box 357660, Seattle, WA 98195-7660, USA.
| | - Emily C Williams
- Health Services Research & Development (HSR&D), Seattle-Denver Center of Innovation for Veteran-Centered & Value-Driven Care, Veterans Affairs (VA) Puget Sound Health Care System, 1660 S. Columbian Way, S-152, Seattle, WA 98108, USA; Kaiser Permanente Washington Health Research Institute, 1730 Minor Ave, Seattle, WA 98101, USA; Department of Health Services, University of Washington, 1959 NE Pacific St., Box 357660, Seattle, WA 98195-7660, USA.
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26
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Madenci AL, Madsen CK, Kwon NK, Wolf LL, Sonderman KA, Zalieckas JM, Rice-Townsend SE, Haider AH, Ricca RL, Weil BR, Weldon CB, Koehlmoos TP. Comparison of Military Health System Data Repository and American College of Surgeons National Surgical Quality Improvement Program-Pediatric. BMC Pediatr 2019; 19:419. [PMID: 31703566 PMCID: PMC6839070 DOI: 10.1186/s12887-019-1795-x] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2019] [Accepted: 10/21/2019] [Indexed: 11/10/2022] Open
Abstract
Background Given the rarity of pediatric surgical disease, it is important to consider available large-scale data resources as a means to better study and understand relevant disease-processes and their treatments. The Military Health System Data Repository (MDR) includes claims-based information for > 3 million pediatric patients who are dependents of members and retirees of the United States Armed Services, but has not been externally validated. We hypothesized that demographics and selected outcome metrics would be similar between MDR and the previously validated American College of Surgeons National Surgical Quality Improvement Program-Pediatric (NSQIP-P) for several common pediatric surgical operations. Methods We selected five commonly performed pediatric surgical operations: appendectomy, pyeloplasty, pyloromyotomy, spinal arthrodesis for scoliosis, and facial reconstruction for cleft palate. Among children who underwent these operations, we compared demographics (age, sex, and race) and clinical outcomes (length of hospital stay [LOS] and mortality) in the MDR and NSQIP-P, including all available overlapping years (2012–2014). Results Age, sex, and race were generally similar between the NSQIP-P and MDR. Specifically, these demographics were generally similar between the resources for appendectomy (NSQIP-P, n = 20,602 vs. MDR, n = 4363; median age 11 vs. 12 years; female 40% vs. 41%; white 75% vs. 84%), pyeloplasty (NSQIP-P, n = 786 vs. MDR, n = 112; median age 0.9 vs. 2 years; female 28% vs. 28%; white 71% vs. 80%), pyloromyotomy, (NSQIP-P, n = 3827 vs. MDR, n = 227; median age 34 vs. < 1 year, female 17% vs. 16%; white 76% vs. 89%), scoliosis surgery (NSQIP-P, n = 5743 vs. MDR, n = 95; median age 14.2 vs. 14 years; female 75% vs. 67%; white 72% vs. 75%), and cleft lip/palate repair (NSQIP-P, n = 6202 vs. MDR, n = 749; median age, 1 vs. 1 year; female 42% vs. 45%; white 69% vs. 84%). Length of stay and 30-day mortality were similar between resources. LOS and 30-day mortality were also similar between datasets. Conclusion For the selected common pediatric surgical operations, patients included in the MDR were comparable to those included in the validated NSQIP-P. The MDR may comprise a valuable clinical outcomes research resource, especially for studying infrequent diseases with follow-up beyond the 30-day peri-operative period.
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Affiliation(s)
- Arin L Madenci
- Department of Surgery, Boston Children's Hospital and Harvard Medical School, Boston, MA, USA. .,Department of Surgery, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA. .,Center for Surgery and Public Health, Boston, MA, USA.
| | - Cathaleen K Madsen
- Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., Bethesda, MD, USA
| | | | - Lindsey L Wolf
- Department of Surgery, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA.,Center for Surgery and Public Health, Boston, MA, USA
| | - Kristin A Sonderman
- Department of Surgery, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA.,Center for Surgery and Public Health, Boston, MA, USA
| | - Jill M Zalieckas
- Department of Surgery, Boston Children's Hospital and Harvard Medical School, Boston, MA, USA.,Center for Surgery and Public Health, Boston, MA, USA
| | - Samuel E Rice-Townsend
- Department of Surgery, Boston Children's Hospital and Harvard Medical School, Boston, MA, USA.,Center for Surgery and Public Health, Boston, MA, USA
| | - Adil H Haider
- Department of Surgery, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA.,Center for Surgery and Public Health, Boston, MA, USA
| | - Robert L Ricca
- Uniformed Services University of the Health Sciences, Bethesda, MD, USA
| | - Brent R Weil
- Department of Surgery, Boston Children's Hospital and Harvard Medical School, Boston, MA, USA.,Center for Surgery and Public Health, Boston, MA, USA
| | - Christopher B Weldon
- Department of Surgery, Boston Children's Hospital and Harvard Medical School, Boston, MA, USA.,Center for Surgery and Public Health, Boston, MA, USA
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27
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Schoenfeld AJ, Kaji AH, Haider AH. Practical Guide to Surgical Data Sets: Military Health System Tricare Encounter Data. JAMA Surg 2019; 153:679-680. [PMID: 29617526 DOI: 10.1001/jamasurg.2018.0480] [Citation(s) in RCA: 71] [Impact Index Per Article: 14.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Affiliation(s)
- Andrew J Schoenfeld
- Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, Massachusetts.,Harvard Medical School, Boston, Massachusetts.,Department of Orthopaedic Surgery, Brigham and Women's Hospital, Boston, Massachusetts
| | - Amy H Kaji
- Harbor-University of California-Los Angeles Medical Center, Torrance.,Statistical Editor
| | - Adil H Haider
- Harvard Medical School, Boston, Massachusetts.,Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, Massachusetts.,Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts.,Deputy Editor
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28
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Morgan AE, Dewey E, Mudd JO, Gelow JM, Davis J, Song HK, Tibayan FA, Bhamidipati CM. The role of estrogen, immune function and aging in heart transplant outcomes. Am J Surg 2019; 218:737-743. [DOI: 10.1016/j.amjsurg.2019.07.007] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2019] [Revised: 05/05/2019] [Accepted: 07/16/2019] [Indexed: 11/24/2022]
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29
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Chaudhary MA, de Jager E, Bhulani N, Kwon NK, Haider AH, Goralnick E, Koehlmoos TP, Schoenfeld AJ. No Racial Disparities In Surgical Care Quality Observed After Coronary Artery Bypass Grafting In TRICARE Patients. Health Aff (Millwood) 2019; 38:1307-1312. [DOI: 10.1377/hlthaff.2019.00265] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Affiliation(s)
- Muhammad Ali Chaudhary
- Muhammad Ali Chaudhary is a research fellow in the Center for Surgery and Public Health, Brigham and Women’s Hospital and Harvard Medical School, in Boston, Massachusetts
| | - Elzerie de Jager
- Elzerie de Jager is a research fellow in the Center for Surgery and Public Health, Brigham and Women’s Hospital and Harvard Medical School
| | - Nizar Bhulani
- Nizar Bhulani is a research fellow in the Center for Surgery and Public Health, Brigham and Women’s Hospital and Harvard Medical School
| | - Nicollette K. Kwon
- Nicollette K. Kwon is a data analyst in the Center for Surgery and Public Health, Brigham and Women’s Hospital and Harvard Medical School
| | - Adil H. Haider
- Adil H. Haider is the dean of the Medical College, Aga Khan University, in Karachi, Pakistan, and the director of disparities and emerging trauma systems in the Center for Surgery and Public Health, Brigham and Women’s Hospital and Harvard Medical School
| | - Eric Goralnick
- Eric Goralnick is the medical director of the Brigham Health Access Center and Emergency Preparedness and an assistant professor in the Department of Emergency Medicine, Brigham and Women’s Hospital and Harvard Medical School
| | - Tracey Pérez Koehlmoos
- Tracey Pérez Koehlmoos is an associate professor in the Department of Preventive Medicine and Biostatistics and principal investigator of the Health Services Research Program, Uniformed Services University of the Health Sciences, in Bethesda, Maryland
| | - Andrew J. Schoenfeld
- Andrew J. Schoenfeld is an associate professor in the Department of Orthopaedic Surgery, Brigham and Women’s Hospital and Harvard Medical School
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Oliphant BW, Harris CA, Cain-Nielsen AH, Goulet JA, Hemmila MR. Not Further Specified: Unclassified Orthopedic Injuries in Trauma Registries, Cause for Concern? J Surg Res 2019; 244:521-527. [PMID: 31336245 DOI: 10.1016/j.jss.2019.06.065] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2019] [Revised: 04/18/2019] [Accepted: 06/14/2019] [Indexed: 10/26/2022]
Abstract
BACKGROUND Data accuracy is essential to obtaining correct results and making appropriate conclusions in outcomes research. Few have examined the quality of data that is used in studies involving orthopedic surgery. A nonspecific data entry has the potential to affect the results of a study or the ability to appropriately risk adjust for treatments and outcomes. This study evaluated the proportion of Not Further Specified (NFS) orthopedic injury codes found into two large trauma registries. MATERIALS Data from the National Trauma Data Bank (NTDB) from 2011 to 2015 and from the Michigan Trauma Quality Improvement Program (MTQIP) 2011-2017 were used. We selected multiple orthopedic injuries classified via the Abbreviated Injury Scale, version 2005 (AIS2005) and calculated the percentage of NFS entries for each specific injury. RESULTS There were a substantial proportion of fractures classified as NFS in each registry, 18.5% (range 2.4%-67.9%) in MTQIP and 27% (range 6.0%-68.5%) in the NTDB. There were significantly more NFS entries when the fractures were complex versus simple in both MTQIP (34.5% versus 9.6%, P < 0.001) and the NTDB (41.8% versus 15.7%, P < 0.001). The level of trauma center affected the proportion of NFS codes differently between the registries. CONCLUSIONS The proportion of nonspecific entries in these two large trauma registries is concerning. These data can affect the results and conclusions from research studies as well as impact our ability to truly risk adjust for treatments and outcomes. Further studies should explore the reasons for these findings.
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Affiliation(s)
- Bryant W Oliphant
- Department of Orthopaedic Surgery, University of Michigan, Ann Arbor, Michigan.
| | - Chelsea A Harris
- Department of Surgery, University of Maryland, Baltimore, Maryland
| | | | - James A Goulet
- Department of Orthopaedic Surgery, University of Michigan, Ann Arbor, Michigan
| | - Mark R Hemmila
- Department of Surgery, University of Michigan, Ann Arbor, Michigan
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Rahman N, Ng SHX, Ramachandran S, Wang DD, Sridharan S, Tan CS, Khoo A, Tan XQ. Drivers of hospital expenditure and length of stay in an academic medical centre: a retrospective cross-sectional study. BMC Health Serv Res 2019; 19:442. [PMID: 31266515 PMCID: PMC6604431 DOI: 10.1186/s12913-019-4248-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2018] [Accepted: 06/12/2019] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND As healthcare expenditure and utilization continue to rise, understanding key drivers of hospital expenditure and utilization is crucial in policy development and service planning. This study aims to investigate micro drivers of hospital expenditure and length of stay (LOS) in an Academic Medical Centre. METHODS Data corresponding to 285,767 patients and 207,426 inpatient visits was extracted from electronic medical records of the National University of Hospital in Singapore between 2005 to 2013. Generalized linear models and generalized estimating equations were employed to build patient and inpatient visit models respectively. The patient models provide insight on the factors affecting overall expenditure and LOS, whereas the inpatient visit models provide insight on how expenditure and LOS accumulate longitudinally. RESULTS Although adjusted expenditure and LOS per inpatient visit were largely similar across socio-economic status (SES) groups, patients of lower SES groups accumulated greater expenditure and LOS over time due to more frequent visits. Admission to a ward class with greater government subsidies was associated with higher expenditure and LOS per inpatient visit. Inpatient death was also associated with higher expenditure per inpatient visit. Conditions that drove patient expenditure and LOS were largely similar, with mental illnesses affecting LOS to a larger extent. These observations on condition drivers largely held true at visit-level. CONCLUSIONS The findings highlight the importance of distinguishing the drivers of patient expenditure and inpatient utilization at the patient-level from those at the visit-level. This allows better understanding of the drivers of healthcare utilization and how utilization accumulates longitudinally, important for health policy and service planning.
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Affiliation(s)
- Nabilah Rahman
- Centre for Health Services and Policy Research, Saw Swee Hock School of Public Health, National University of Singapore and National University Health System, 12 Science Drive 2, Singapore, Singapore
| | - Sheryl Hui-Xian Ng
- Centre for Health Services and Policy Research, Saw Swee Hock School of Public Health, National University of Singapore and National University Health System, 12 Science Drive 2, Singapore, Singapore
| | - Sravan Ramachandran
- Centre for Health Services and Policy Research, Saw Swee Hock School of Public Health, National University of Singapore and National University Health System, 12 Science Drive 2, Singapore, Singapore
| | - Debby D. Wang
- Centre for Health Services and Policy Research, Saw Swee Hock School of Public Health, National University of Singapore and National University Health System, 12 Science Drive 2, Singapore, Singapore
| | - Srinath Sridharan
- Centre for Health Services and Policy Research, Saw Swee Hock School of Public Health, National University of Singapore and National University Health System, 12 Science Drive 2, Singapore, Singapore
| | - Chuen Seng Tan
- Saw Swee Hock School of Public Health, National University of Singapore and National University Health System, 12 Science Drive 2, Singapore, Singapore
| | - Astrid Khoo
- Regional Health System Planning Office, National University Health System, 1E Kent Ridge Road, Singapore, Singapore
| | - Xin Quan Tan
- Saw Swee Hock School of Public Health, National University of Singapore and National University Health System, 12 Science Drive 2, Singapore, Singapore
- Regional Health System Planning Office, National University Health System, 1E Kent Ridge Road, Singapore, Singapore
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Chaudhary MA, Schoenfeld AJ, Koehlmoos TP, Cooper Z, Haider AH. Prolonged ICU stay and its association with 1-year trauma mortality: An analysis of 19,000 American patients. Am J Surg 2019; 218:21-26. [DOI: 10.1016/j.amjsurg.2019.01.025] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2018] [Revised: 12/07/2018] [Accepted: 01/24/2019] [Indexed: 12/20/2022]
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Increasing Burden of Hepatic Encephalopathy Among Hospitalized Adults: An Analysis of the 2010-2014 National Inpatient Sample. Dig Dis Sci 2019; 64:1448-1457. [PMID: 30863953 DOI: 10.1007/s10620-019-05576-9] [Citation(s) in RCA: 39] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2018] [Accepted: 03/02/2019] [Indexed: 12/12/2022]
Abstract
BACKGROUND Hepatic encephalopathy (HE) is associated with substantial morbidity and mortality, contributing significant burden on healthcare systems. AIM We aim to evaluate trends in clinical and economic burden of HE among hospitalized adults in the USA. METHODS Using the 2010-2014 National Inpatient Sample, we identified adults hospitalized with HE using ICD-9-CM codes. Annual trends in hospitalizations with HE, in-hospital mortality, and hospital charges were stratified by the presence of acute liver failure (ALF) or cirrhosis. Adjusted multivariable regression models were evaluated for predictors of in-hospital mortality and hospitalization charges. RESULTS Among 142,860 hospitalizations with HE (mean age 59.3 years, 57.8% male), 67.7% had cirrhosis and 3.9% ALF. From 2010 to 2014, total number of hospitalizations with HE increased by 24.4% (25,059 in 2010 to 31,182 in 2014, p < 0.001). Similar increases were seen when stratified by ALF (29.7% increase) and cirrhosis (29.7% increase). Overall in-hospital mortality decreased from 13.4% (2010) to 12.3% (2014) (p = 0.001), with similar decreases observed in ALF and cirrhosis. Total inpatient charges increased by 46.0% ($8.15 billion, 2010 to $11.9 billion, 2014). On multivariable analyses, ALF was associated with significantly higher odds of in-hospital mortality (OR 5.37; 95% CI 4.97-5.80; p < 0.001) as well as higher mean inpatient charges (122.6% higher; 95% CI + 115.0-130.3%; p < 0.001) compared to cirrhosis. The presence of ascites, hepatocellular carcinoma, and hepatorenal syndrome was associated with increased mortality. CONCLUSIONS The clinical and economic burden of hospitalizations with HE in the USA continues to rise. In 2014, estimated national economic burden of hospitalizations with HE reached $11.9 billion.
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Gild P, Nguyen DD, Fletcher SA, Cole AP, Lipsitz SR, Kibel AS, Fisch M, Preston MA, Trinh QD. Contemporary Survival Rates for Muscle-Invasive Bladder Cancer Treated With Definitive or Non-Definitive Therapy. Clin Genitourin Cancer 2019; 17:e488-e493. [PMID: 30837209 DOI: 10.1016/j.clgc.2019.01.009] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2019] [Accepted: 01/19/2019] [Indexed: 12/29/2022]
Abstract
INTRODUCTION Definitive, curatively intended therapy for muscle-invasive bladder cancer can be associated with significant morbidity and adverse effects on quality of life, leaving patients reluctant to opt for these interventions. We sought to provide perspective to patients and clinicians exploring therapy options. MATERIALS AND METHODS We examined stage-by-stage overall survival of definitive therapy (DT) (either radical cystectomy in conjunction with neoadjuvant chemotherapy or trimodal therapy) versus non-DT (including palliative transurethral resection, chemotherapy and radiation treatment) among 42,144 patients within the National Cancer Database (2004-2012). RESULTS The median overall survival stratified by receipt of DT versus non-DT was 45.3 versus 16.4 months, 26.7 versus 9.6 months, and 21.2 versus 7.5 months in American Joint Committee on Cancer stages II, III, and IV, respectively. In multivariable Cox regression analysis, DT conferred a significant survival benefit in all stages, most pronounced in American Joint Committee on Cancer stage IV (hazard ratio, 0.46; 95% confidence interval, 0.43-0.49; P < .001). CONCLUSION Despite potentially significant morbidity and adverse effects on quality of life, DT is associated with a sizable survival benefit.
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Affiliation(s)
- Philipp Gild
- Center for Surgery and Public Health, Division of Urologic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA; Department of Urology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - David-Dan Nguyen
- Center for Surgery and Public Health, Division of Urologic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA; Faculty of Medicine, McGill University, Montreal, Quebec, Canada
| | - Sean A Fletcher
- Center for Surgery and Public Health, Division of Urologic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Alexander P Cole
- Center for Surgery and Public Health, Division of Urologic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Stuart R Lipsitz
- Center for Surgery and Public Health, Division of Urologic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Adam S Kibel
- Center for Surgery and Public Health, Division of Urologic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Margit Fisch
- Department of Urology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Mark A Preston
- Center for Surgery and Public Health, Division of Urologic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Quoc-Dien Trinh
- Center for Surgery and Public Health, Division of Urologic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA.
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Cannabis Abuse or Dependence During Pregnancy: A Population-Based Cohort Study on 12 Million Births. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2018; 41:623-630. [PMID: 30448107 DOI: 10.1016/j.jogc.2018.09.009] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2018] [Revised: 08/23/2018] [Accepted: 08/23/2018] [Indexed: 01/03/2023]
Abstract
OBJECTIVE Cannabis is the most commonly used recreational drug during pregnancy in the United States. This study aimed to describe the rate of cannabis dependence or abuse use during pregnancy and its effect on obstetrical and neonatal outcomes. METHODS A retrospective population-based cohort of births in the United States between 1999 and 2013 was created using data from the National Inpatient Sample. Births to mothers who reported cannabis dependence or abuse were identified using ICD-9 codes, and the effect on various obstetrical and neonatal outcomes was assessed using logistic regression, adjusting for relevant confounders (Canadian Task Force Classification II-2). RESULTS A total of 12 578 557 births were included in our analysis. The incidence of cannabis abuse or dependence rose from 3.22 in 1000 births in 1999 to 8.55 in 1000 births in 2013 (P < 0.0001). Women reporting cannabis dependence or abuse were more likely to have a preterm premature rupture of membranes (odds ratio [OR] 1.46; 95% confidence interval [CI] 1.35-1.58), a hospital stay of >7 days (OR 1.17; 95% CI 1.11-1.23), and an intrauterine fetal demise (OR 1.50; 95% CI 1.39-1.62). Neonates born to exposed mothers had a higher risk of prematurity (OR 1.40; 95% CI 1.36-1.43) and growth restriction (OR 1.35; 95% CI 1.30-1.41). CONCLUSION Cannabis use during pregnancy steadily increased over the study period. Users of cannabis during gestation were more likely to have adverse outcomes during delivery and require longer periods of hospitalization. Neonates born to exposed mothers were more likely to be born preterm and underweight.
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Changoor NR, Pak LM, Nguyen LL, Bleday R, Trinh Q, Koehlmoos T, Learn PA, Haider AH, Goldberg JE. Effect of an equal‐access military health system on racial disparities in colorectal cancer screening. Cancer 2018; 124:3724-3732. [DOI: 10.1002/cncr.31637] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2018] [Revised: 05/16/2018] [Accepted: 05/21/2018] [Indexed: 01/30/2023]
Affiliation(s)
- Navin R. Changoor
- Center for Surgery and Public Health, Harvard Medical School and Harvard School of Public HealthBoston Massachusetts
- Howard University College of MedicineWashington District of Columbia
| | - Linda M. Pak
- Center for Surgery and Public Health, Harvard Medical School and Harvard School of Public HealthBoston Massachusetts
- Department of SurgeryBrigham and Women's HospitalBoston Massachusetts
| | - Louis L. Nguyen
- Center for Surgery and Public Health, Harvard Medical School and Harvard School of Public HealthBoston Massachusetts
| | - Ronald Bleday
- Department of SurgeryBrigham and Women's HospitalBoston Massachusetts
| | - Quoc‐Dien Trinh
- Center for Surgery and Public Health, Harvard Medical School and Harvard School of Public HealthBoston Massachusetts
| | - Tracey Koehlmoos
- Uniformed Services University of the Health SciencesBethesda Maryland
| | - Peter A. Learn
- Uniformed Services University of the Health SciencesBethesda Maryland
| | - Adil H. Haider
- Center for Surgery and Public Health, Harvard Medical School and Harvard School of Public HealthBoston Massachusetts
- Department of SurgeryBrigham and Women's HospitalBoston Massachusetts
| | - Joel E. Goldberg
- Center for Surgery and Public Health, Harvard Medical School and Harvard School of Public HealthBoston Massachusetts
- Department of SurgeryBrigham and Women's HospitalBoston Massachusetts
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Does Orthopaedic Outpatient Care Reduce Emergency Department Utilization After Total Joint Arthroplasty? Clin Orthop Relat Res 2018; 476:1655-1662. [PMID: 29794858 PMCID: PMC6259727 DOI: 10.1097/01.blo.0000533620.66105.ef] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Emergency department (ED) visits after elective surgical procedures are a potential target for interventions to reduce healthcare costs. More than 1 million total joint arthroplasties (TJAs) are performed each year with postsurgical ED utilization estimated in the range of 10%. QUESTIONS/PURPOSES We asked whether (1) outpatient orthopaedic care was associated with reduced ED utilization and (2) whether there were identifiable factors associated with ED utilization within the first 30 and 90 days after TJA. METHODS An analysis of adult TRICARE beneficiaries who underwent TJA (2006-2014) was performed. TRICARE is the insurance program of the Department of Defense, covering > 9 million beneficiaries. ED use within 90 days of surgery was the primary outcome and postoperative outpatient orthopaedic care the primary explanatory variable. Patient demographics (age, sex, race, beneficiary category), clinical characteristics (length of hospital stay, prior comorbidities, complications), and environment of care were used as covariates. Logistic regression adjusted for all covariates was performed to determine factors associated with ED use. RESULTS We found that orthopaedic outpatient care (odds ratio [OR], 0.73; 95% confidence interval [CI], 0.68-0.77) was associated with lower odds of ED use within 90 days. We also found that index hospital length of stay (OR, 1.07; 95% CI, 1.04-1.10), medical comorbidities (OR, 1.16; 95% CI, 1.08-1.24), and complications (OR, 2.47; 95% CI, 2.24-2.72) were associated with higher odds of ED use. CONCLUSIONS When considering that at 90 days, only 3928 patients sustained a complication, a substantial number of ED visits (11,486 of 15,414 [75%]) after TJA may be avoidable. Enhancing access to appropriate outpatient care with improved discharge planning may reduce ED use after TJA. Further research should be directed toward unpacking the situations, outside of complications, that drive patients to access the ED and devise interventions that could mitigate such behavior. LEVEL OF EVIDENCE Level III, therapeutic study.
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Outpatient Spine Clinic Utilization is Associated With Reduced Emergency Department Visits Following Spine Surgery. Spine (Phila Pa 1976) 2018; 43:E836-E841. [PMID: 29257029 DOI: 10.1097/brs.0000000000002529] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Review of TRICARE claims (2006-2014) data to assess Emergency Department (ED) utilization following spine surgery. OBJECTIVE The aim of this study was to determine utilization rates and predictors of ED utilization following spine surgical interventions. SUMMARY OF BACKGROUND DATA Visits to the ED following surgical intervention represent an additional stress to the healthcare system. While factors associated with readmission following spine surgery have been studied, drivers of postsurgical ED visits, including appropriate and inappropriate use, remain underinvestigated. METHODS TRICARE claims were queried to identify patients who had undergone one of three common spine procedures (lumbar arthrodesis, discectomy, decompression). ED utilization at 30- and 90 days was assessed as the primary outcome. Outpatient spine surgical clinic utilization was considered the primary predictor variable. Multivariable logistic regression was used to adjust for confounders. RESULTS Between 2006 and 2014, 48,868 patients met inclusion criteria. Fifteen percent (n = 7183) presented to the ED within 30 days postdischarge. By 90 days, 29% of patients (n = 14,388) presented to an ED. The 30- and 90-day complication rates were 6% (n = 2802) and 8% (n = 4034), respectively, and readmission rates were 5% (n = 2344) and 8% (n = 3842), respectively. Use of outpatient spine clinic services significantly reduced the likelihood of ED utilization at 30 [odds ratio (OR) 0.48; 95% confidence interval (95% CI) 0.46-0.53] and 90 days (OR 0.55; 95% CI 0.52-0.57). CONCLUSION Within 90 days following spine surgery, 29% of patients sought care in the ED. However, only one-third of these patients had a complication recorded, and even fewer were readmitted. This suggests a high rate of unnecessary ED utilization. Outpatient utilization of spine clinics was the only factor independently associated with a reduced likelihood of ED utilization. LEVEL OF EVIDENCE 3.
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Schaumeier MJ, Hawkins AT, Hevelone ND, Sethi RKV, Nguyen LL. Association of Treatment for Critical Limb Ischemia with Gender and Hospital Volume. Am Surg 2018. [DOI: 10.1177/000313481808400668] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Critical limb ischemia (CLI) is a frequent and major vascular problem and can lead to amputation and death despite surgical revascularization. Women have been shown to have 3 to 4 per cent lower revascularization rates for CLI compared with men as well as inferior outcomes. We hypothesize that this difference is a result of women being more likely admitted to low-volume hospitals, which in turn perform fewer revascularizations. Prospective cohort study. Data from the Nationwide Inpatient Sample 2007 to 2010 were used to identify admissions with primary International Classification of Diseases-9 codes for CLI (International Classification of Diseases-9 codes: 440.22, 440.23, 440.24, 707.1, 707.10–707.15, or 707.19). Hospitals were grouped in quintiles by annual revascularization procedures. Bivariate analyses were performed and multivariable logistic regression was used to analyze the odds of revascularization, amputation, and mortality while controlling for patient and hospital-level factors. Of 113,631 admissions, 54,370 (47.8%) were women, who were more likely admitted to low-volume hospitals (very low: 49.6% vs very high: 47.1%; P < 0.001). Revascularization rates were lower in women (31.6% vs 35.1%, P < 0.001) across all volume quintiles, whereas the difference was greatest in the use of open surgical revascularization (12.5% vs 16.0%, P < 0.001). In multivariable analysis, female gender [odds ratio (OR) 0.87, 95% confidence interval (CI) 0.83–0.92, P < 0.001] and very-low hospital volume (OR 0.21, 95% CI 0.17–0.26, P < 0.001) were both significantly associated with lower rates of revascularization. Women had lower odds of major amputation compared with men (OR 0.75, 95% CI 0.69–0.82, P < 0.001), whereas treatment in a very high-volume hospital was associated with increased odds for amputation (OR 1.37, 95% CI 1.09–1.73, P = 0.008). Neither gender nor hospital volume were independently associated with in-hospital mortality in the multivariable regression model. Women are more likely to be admitted to low-volume hospitals for treatment of CLI. Because of this, they are less likely to undergo revascularization, although they also had lower rates of major amputation.
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Affiliation(s)
- Maria J. Schaumeier
- Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, Massachusetts
- Department of Surgery, University Hospital Basel, Basel, Switzerland
| | - Alexander T. Hawkins
- Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, Massachusetts
| | - Nathanael D. Hevelone
- Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, Massachusetts
| | | | - Louis L. Nguyen
- Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
- Division of Vascular and Endovascular Surgery, Brigham and Women's Hospital, Boston, Massachusetts
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Rhon DI, Snodgrass SJ, Cleland JA, Greenlee TA, Sissel CD, Cook CE. Comparison of Downstream Health Care Utilization, Costs, and Long-Term Opioid Use: Physical Therapist Management Versus Opioid Therapy Management After Arthroscopic Hip Surgery. Phys Ther 2018; 98:348-356. [PMID: 29669080 DOI: 10.1093/ptj/pzy019] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2017] [Accepted: 02/06/2018] [Indexed: 02/09/2023]
Abstract
BACKGROUND Physical therapy and opioid prescriptions are common after hip surgery, but are sometimes delayed or not used. OBJECTIVE The objective of this study was to compare downstream health care utilization and opioid use following hip surgery for different patterns of physical therapy and prescription opioids. DESIGN The design of this study was an observational cohort. METHODS Health care utilization was abstracted from the Military Health System Data Repository for patients who were 18 to 50 years old and were undergoing arthroscopic hip surgery between 2004 and 2013. Patients were grouped into those receiving an isolated treatment (only opioids or only physical therapy) and those receiving both treatments on the basis of timing (opioid first or physical therapy first). Outcomes included overall health care visits and costs, hip-related visits and costs, additional surgeries, and opioid prescriptions. RESULTS Of 1870 total patients, 76.8% (n = 1437) received physical therapy, 71.6% (n = 1339) received prescription opioids, and 1073 (56.1%) received both physical therapy and opioids. Because 24 patients received both opioids and physical therapy on the same day, they were eventually removed the final timing-of-care analysis. Adjusted hip-related mean costs were the same in both groups receiving isolated treatments (${\$}$11,628 vs ${\$}$11,579), but the group receiving only physical therapy had significantly lower overall total health care mean costs (${\$}$18,185 vs ${\$}$23,842) and fewer patients requiring another hip surgery. For patients receiving both treatments, mean hip-related downstream costs were significantly higher in the group receiving opioids first than in the group receiving physical therapy first (${\$}$18,806 vs ${\$}$16,955) and resulted in greater opioid use (7.83 vs 4.14 prescriptions), greater total days' supply of opioids (90.17 vs 44.30 days), and a higher percentage of patients with chronic opioid use (69.5% vs 53.2%). LIMITATIONS Claims data were limited by the accuracy of coding, and observational data limit inferences of causality. CONCLUSIONS Physical therapy first was associated with lower hip-related downstream costs and lower opioid use than opioids first; physical therapy instead of opioids was associated with less total downstream health care utilization. These results need to be validated in prospective controlled trials.
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Affiliation(s)
- Daniel I Rhon
- Baylor University Doctoral Physical Therapy Program, 3630 Stanley Road, Bldg 2841, Suite 2301, San Antonio, TX 78234. Dr Rhon is a board-certified orthopaedic clinical specialist and a fellow of the American Academy of Orthopedic Manual Therapists
| | - Suzanne J Snodgrass
- Discipline of Physiotherapy, School of Health Sciences, The University of Newcastle, Callaghan, New South Wales, Australia
| | - Joshua A Cleland
- Physical Therapy Department, Franklin Pierce College, Concord, New Hampshire. Dr Cleland is a board-certified orthopaedic clinical specialist and a fellow of the American Academy of Orthopedic Manual Therapists
| | - Tina A Greenlee
- US Army Brooke Army Medical Center, Center for the Intrepid, Fort Sam Houston, Texas
| | | | - Chad E Cook
- Doctor of Physical Therapy Division, Duke University, Durham, North Carolina. Dr Cook is a board-certified orthopaedic clinical specialist and a fellow of the American Academy of Orthopedic Manual Physical Therapists
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Universal insurance and an equal access healthcare system eliminate disparities for Black patients after traumatic injury. Surgery 2018; 163:651-656. [DOI: 10.1016/j.surg.2017.09.045] [Citation(s) in RCA: 38] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2017] [Revised: 09/05/2017] [Accepted: 09/13/2017] [Indexed: 11/23/2022]
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Rhon DI, Clewley D, Young JL, Sissel CD, Cook CE. Leveraging healthcare utilization to explore outcomes from musculoskeletal disorders: methodology for defining relevant variables from a health services data repository. BMC Med Inform Decis Mak 2018; 18:10. [PMID: 29386010 PMCID: PMC5793373 DOI: 10.1186/s12911-018-0588-8] [Citation(s) in RCA: 40] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2017] [Accepted: 01/17/2018] [Indexed: 12/29/2022] Open
Abstract
Background Large healthcare databases, with their ability to collect many variables from daily medical practice, greatly enable health services research. These longitudinal databases provide large cohorts and longitudinal time frames, allowing for highly pragmatic assessment of healthcare delivery. The purpose of this paper is to discuss the methodology related to the use of the United States Military Health System Data Repository (MDR) for longitudinal assessment of musculoskeletal clinical outcomes, as well as address challenges of using this data for outcomes research. Methods The Military Health System manages care for approximately 10 million beneficiaries worldwide. Multiple data sources pour into the MDR from multiple levels of care (inpatient, outpatient, military or civilian facility, combat theater, etc.) at the individual patient level. To provide meaningful and descriptive coding for longitudinal analysis, specific coding for timing and type of care, procedures, medications, and provider type must be performed. Assumptions often made in clinical trials do not apply to these cohorts, requiring additional steps in data preparation to reduce risk of bias. The MDR has a robust system in place to validate the quality and accuracy of its data, reducing risk of analytic error. Details for making this data suitable for analysis of longitudinal orthopaedic outcomes are provided. Results Although some limitations exist, proper preparation and understanding of the data can limit bias, and allow for robust and meaningful analyses. There is the potential for strong precision, as well as the ability to collect a wide range of variables in very large groups of patients otherwise not captured in traditional clinical trials. This approach contributes to the improved understanding of the accessibility, quality, and cost of care for those with orthopaedic conditions. Conclusion The MDR provides a robust pool of longitudinal healthcare data at the person-level. The benefits of using the MDR database appear to outweigh the limitations.
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Affiliation(s)
- Daniel I Rhon
- Center for the Intrepid, Brooke Army Medical Center, 3551 Roger Brooke Drive, San Antonio, TX, 78234, USA.
| | - Derek Clewley
- Baylor University, 3630 Stanley Road, Bldg 2841, Suite 1301; Joint Base San Antonio - Fort Sam Houston, San Antonio, TX, 78234, USA
| | - Jodi L Young
- Division of Physical Therapy, Department of Orthopedics, Duke University, 2200 W. Main Street, Durham, NC, 27701, USA
| | - Charles D Sissel
- Department of Physical Therapy, Arizona School of Health Sciences, 5850 E. Still Circle, Mesa, AZ, 85206, USA
| | - Chad E Cook
- Headquarters, U.S. Army Medical Command, Analysis & Evaluation Division, 3630 Stanley Road; Joint Base San Antonio - Fort Sam Houston, San Antonio, TX, 78234, USA
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Ranjit A, Jiang W, Zhan T, Kimsey L, Staat B, Witkop CT, Little SE, Haider AH, Robinson JN. Intrapartum obstetric care in the United States military: Comparison of military and civilian care systems within TRICARE. Birth 2017; 44:337-344. [PMID: 28833512 DOI: 10.1111/birt.12298] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2017] [Revised: 06/09/2017] [Accepted: 06/09/2017] [Indexed: 11/28/2022]
Abstract
BACKGROUND Expectant mothers who are beneficiaries of TRICARE (universal insurance to United States Armed Services members and their dependents) can choose to receive care within direct (salary-based) or purchased (fee-for-service) care systems. We sought to compare frequency of intrapartum obstetric procedures and outcomes such as severe acute maternal morbidity (SAMM) and common postpartum complications between direct and purchased care systems within TRICARE. METHODS TRICARE (2006-2010) claims data were used to identify deliveries. Patient demographics, frequency of types of delivery (noninstrumental vaginal, cesarean, and instrumental vaginal), comorbid conditions, SAMM, and common postpartum complications were compared between the two systems of care. Multivariable models adjusted for patient clinical/demographic factors determined the odds of common complications and SAMM complications in purchased care compared with direct care. RESULTS A total of 440 138 deliveries were identified. Compared with direct care, purchased care had higher frequency (30.9% vs 25.8%, P<.001) and higher adjusted odds (aOR 1.37 [CI 1.34-1.38]) of cesarean delivery. In stratified analysis by mode of delivery, purchased care had lower odds of common complications for all modes of delivery (aOR[CI]:noninstrumental vaginal: 0.72 [0.71-0.74], cesarean: 0.71 [0.68-0.75], instrumental vaginal: 0.64 [0.60-0.68]) than direct care. However, purchased care had higher odds of SAMM complications for cesarean delivery (aOR 1.31 [CI 1.19-1.44]) compared with direct care. CONCLUSION Direct care has a higher vaginal delivery rate but also a higher rate of common complications compared with purchased care. Study of direct and purchased care systems in TRICARE may have potential use as a surrogate for comparing obstetric care between salary-based systems and fee-for-service systems in the United States.
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Affiliation(s)
- Anju Ranjit
- Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard School of Medicine and Harvard School of Public Health, Boston, MA, USA
| | - Wei Jiang
- Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard School of Medicine and Harvard School of Public Health, Boston, MA, USA
| | - Tiannan Zhan
- Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard School of Medicine and Harvard School of Public Health, Boston, MA, USA
| | - Linda Kimsey
- Jiann-Ping Hsu College of Public Health, Georgia Southern University, Statesboro, GA, USA
| | - Bart Staat
- Department of Obstetrics and Gynecology, Uniformed Health Services University, Bethesda, MD, USA
| | - Catherine T Witkop
- Department of Preventive Medicine and Biostatistics, Uniformed Health Services University, Bethesda, MD, USA
| | - Sarah E Little
- Department of Obstetrics and Gynecology, Brigham and Women's Hospital, Boston, MA, USA
| | - Adil H Haider
- Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard School of Medicine and Harvard School of Public Health, Boston, MA, USA
| | - Julian N Robinson
- Department of Obstetrics and Gynecology, Brigham and Women's Hospital, Boston, MA, USA
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Chaudhary MA, Schoenfeld AJ, Harlow AF, Ranjit A, Scully R, Chowdhury R, Sharma M, Nitzschke S, Koehlmoos T, Haider AH. Incidence and Predictors of Opioid Prescription at Discharge After Traumatic Injury. JAMA Surg 2017. [PMID: 28636707 DOI: 10.1001/jamasurg.2017.1685] [Citation(s) in RCA: 86] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Importance In the current health care environment with increased scrutiny and growing concern regarding opioid use and abuse, there has been a push toward greater regulation over prescriptions of opioids. Trauma patients represent a population that may be affected by this regulation, as the incidence of pain at hospital discharge is greater than 95%, and opioids are considered the first line of treatment for pain management. However, the use of opioid prescriptions in trauma patients at hospital discharge has not been explored. Objective To study the incidence and predictors of opioid prescription in trauma patients at discharge in a large national cohort. Design, Setting, and Participants Analysis of adult (18-64 years), opioid-naive trauma patients who were beneficiaries of Military Health Insurance (military personnel and their dependents) treated at both military health care facilities and civilian trauma centers and hospitals between January 1, 2006, and December 31, 2013, was conducted. Patients with burns, foreign body injury, toxic effects, or late complications of trauma were excluded. Prior diagnosis of trauma within 1 year and in-hospital death were also grounds for exclusion. Injury mechanism and severity, comorbid conditions, mental health disorders, and demographic factors were considered covariates. The Drug Enforcement Administration's list of scheduled narcotics was used to query opioid use. Unadjusted and adjusted logistic regression models were used to determine the predictors of opioid prescription. Data analysis was performed from June 7 to August 21, 2016. Exposures Injury mechanism and severity, comorbid conditions, mental health disorders, and demographic factors. Main Outcomes and Measures Prescription of opioid analgesics at discharge. Results Among the 33 762 patients included in the study (26 997 [80.0%] men; mean [SD] age, 32.9 [13.3] years), 18 338 (54.3%) received an opioid prescription at discharge. In risk-adjusted models, older age (45-64 vs 18-24 years: odds ratio [OR], 1.28; 95% CI, 1.13-1.44), marriage (OR, 1.26; 95% CI, 1.20-1.34), and higher Injury Severity Score (≥9 vs <9: OR, 1.40; 95% CI, 1.32-1.48) were associated with a higher likelihood of opioid prescription at discharge. Male sex (OR, 0.76; 95% CI, 0.69-0.83) and anxiety (OR, 0.82; 95% CI, 0.73-0.93) were associated with a decreased likelihood of opioid prescription at discharge. Conclusions and Relevance The incidence of opioid prescription at discharge (54.3%) closely matches the incidence of moderate to severe pain in trauma patients, indicating appropriate prescribing practices. We advocate that injury severity and level of pain-not arbitrary regulations-should inform the decision to prescribe opioids.
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Affiliation(s)
- Muhammad Ali Chaudhary
- Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Andrew J Schoenfeld
- Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts.,Department of Orthopedic Surgery, Brigham and Women's Hospital, Boston, Massachusetts
| | - Alyssa F Harlow
- Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Anju Ranjit
- Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Rebecca Scully
- Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Ritam Chowdhury
- Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Meesha Sharma
- Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Stephanie Nitzschke
- Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts.,Division of Trauma Burn and Surgical Critical Care, Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts
| | - Tracey Koehlmoos
- Uniformed Services University of Health Sciences, Bethesda, Maryland
| | - Adil H Haider
- Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts.,Deputy Editor
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Heuristically repopulated Bayesian ant colony optimization for treating missing values in large databases. Knowl Based Syst 2017. [DOI: 10.1016/j.knosys.2017.06.033] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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Prospective Evaluation of a Multifaceted Intervention to Improve Outcomes in Intensive Care: The Promoting Respect and Ongoing Safety Through Patient Engagement Communication and Technology Study. Crit Care Med 2017; 45:e806-e813. [PMID: 28471886 DOI: 10.1097/ccm.0000000000002449] [Citation(s) in RCA: 46] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Studies comprehensively assessing interventions to improve team communication and to engage patients and care partners in ICUs are lacking. This study examines the effectiveness of a patient-centered care and engagement program in the medical ICU. DESIGN Prospective intervention study. SETTING Medical ICUs at large tertiary care center. PATIENTS Two thousand one hundred five patient admissions (1,030 before and 1,075 during the intervention) from July 2013 to May 2014 and July 2014 to May 2015. INTERVENTIONS Structured patient-centered care and engagement training program and web-based technology including ICU safety checklist, tools to develop shared care plan, and messaging platform. Patient and care partner access to online portal to view health information, participate in the care plan, and communicate with providers. MEASUREMENTS AND MAIN RESULTS Primary outcome was aggregate adverse event rate. Secondary outcomes included patient and care partner satisfaction, care plan concordance, and resource utilization. We included 2,105 patient admissions, (1,030 baseline and 1,075 during intervention periods). The aggregate rate of adverse events fell 29%, from 59.0 per 1,000 patient days (95% CI, 51.8-67.2) to 41.9 per 1,000 patient days (95% CI, 36.3-48.3; p < 0.001), during the intervention period. Satisfaction improved markedly from an overall hospital rating of 71.8 (95% CI, 61.1-82.6) to 93.3 (95% CI, 88.2-98.4; p < 0.001) for patients and from 84.3 (95% CI, 81.3-87.3) to 90.0 (95% CI, 88.1-91.9; p < 0.001) for care partners. No change in care plan concordance or resource utilization. CONCLUSIONS Implementation of a structured team communication and patient engagement program in the ICU was associated with a reduction in adverse events and improved patient and care partner satisfaction.
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Schoenfeld AJ, Nwosu K, Jiang W, Yau AL, Chaudhary MA, Scully RE, Koehlmoos T, Kang JD, Haider AH. Risk Factors for Prolonged Opioid Use Following Spine Surgery, and the Association with Surgical Intensity, Among Opioid-Naive Patients. J Bone Joint Surg Am 2017; 99:1247-1252. [PMID: 28763410 DOI: 10.2106/jbjs.16.01075] [Citation(s) in RCA: 137] [Impact Index Per Article: 19.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND There is a growing concern that the use of prescription opioids following surgical interventions, including spine surgery, may predispose patients to chronic opioid use and abuse. We sought to estimate the proportion of patients using opioids up to 1 year after discharge following common spinal surgical procedures and to identify factors associated with sustained opioid use. METHODS This study utilized 2006 to 2014 data from TRICARE insurance claims obtained from the Military Health System Data Repository. Adults who underwent 1 of 4 common spinal surgical procedures (discectomy, decompression, lumbar posterolateral arthrodesis, or lumbar interbody arthrodesis) were identified. Patients with a history of opioid use in the 6 months preceding surgery were excluded. Posterolateral arthrodesis and interbody arthrodesis were considered procedures of high intensity, and discectomy and decompression, low intensity. Covariates included demographic factors, preoperative diagnoses, comorbidities, postoperative complications, and mental health disorders. Risk-adjusted Cox proportional hazard models were used to evaluate the time to opioid discontinuation. RESULTS This study included 9,991 patients. Eighty-four percent filled at least 1 opioid prescription on discharge. At 30 days following discharge, 8% continued opioid use; at 3 months, 1% continued use; and at 6 months, 0.1%. In the adjusted analysis, the low-intensity surgical procedures were associated with a higher likelihood of discontinuing opioid use (discectomy: hazard ratio [HR] = 1.43, 95% confidence interval [CI] = 1.36 to 1.50; and decompression: HR = 1.34, 95% CI = 1.25 to 1.43). Depression (HR = 0.84, 95% CI = 0.77 to 0.90) was significantly associated with a decreased likelihood of discontinuing opioid use (p < 0.001). CONCLUSIONS By 6 months following discharge, nearly all patients had discontinued opioid use after spine surgery. As only 0.1% of the patients continued opioid use at 6 months following surgery, these results indicate that spine surgery among opioid-naive patients is not a major driver of long-term prescription opioid use. Socioeconomic status and pre-existing mental health disorders may be factors associated with sustained opioid use following spine surgery. LEVEL OF EVIDENCE Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Andrew J Schoenfeld
- 1Department of Orthopaedic Surgery (A.J.S., K.N., and J.D.K.), Department of Surgery (W.J., M.A.C., R.E.S., and A.H.H.), and Center for Surgery and Public Health (A.J.S., W.J., M.A.C., R.E.S., and A.H.H.), Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts 2Tufts University School of Medicine, Boston, Massachusetts 3Department of Preventive Medicine and Biostatistics, Uniformed Services University of the Health Sciences, Bethesda, Maryland
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Siddiqui M, Minhaj M, Mueller A, Tung A, Scavone B, Rana S, Shahul S. Increased Perinatal Morbidity and Mortality Among Asian American and Pacific Islander Women in the United States. Anesth Analg 2017; 124:879-886. [PMID: 28099290 DOI: 10.1213/ane.0000000000001778] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Asian American/Pacific Islanders (AAPIs) are the fastest-growing racial group in the United States. Despite a higher socioeconomic status, AAPI women experience higher rates of maternal morbidity and mortality. METHODS Using the National Inpatient Sample, we performed a retrospective cohort analysis of women who were hospitalized for delivery from 2002 to 2013. The primary outcome variable was inpatient mortality rate, and the presence of severe maternal morbidities was estimated using the Bateman Comorbidity Index, a validated tool for predicting obstetric morbidity. RESULTS AAPI women presenting for delivery between 2003 and 2012 were older, more likely to reside in a zip code in the top quartile of annual income, be privately insured than Caucasian women, and less likely to have a higher Bateman Comorbidity Index. However, AAPI women had a higher likelihood of postpartum hemorrhage (3.4% vs 2.7%, P < .001), uterine atony, severe perineal lacerations, and severe maternal morbidities. Procedures such as transfusion, hysterectomy, and mechanical ventilation were also more common in AAPI women. Furthermore, AAPI women had a higher mortality rate that persisted despite adjustment for an apparently higher income and comorbidities (odds ratio 1.72, 95% confidence interval: 1.14-2.59, P = .01). CONCLUSIONS Despite having a higher socioeconomic status, AAPI women had higher rates of maternal mortality during hospitalization for delivery. This increase persisted even after adjustment for factors known to affect peripartum outcomes. Further investigation is needed to better clarify the causes of racial differences in maternal morbidity and mortality.
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Affiliation(s)
- Maryam Siddiqui
- From the *Divisions of General Obstetrics & Gynecology and Maternal Fetal Medicine, Department of Obstetrics and Gynecology, University of Chicago, Chicago, Illinois; †Department of Anesthesia and Critical Care, University of Chicago, Chicago, Illinois; and ‡Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
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Ranjit A, Sharma M, Romano A, Jiang W, Staat B, Koehlmoos T, Haider AH, Little SE, Witkop CT, Robinson JN, Cohen SL. Does Universal Insurance Mitigate Racial Differences in Minimally Invasive Hysterectomy? J Minim Invasive Gynecol 2017; 24:790-796. [DOI: 10.1016/j.jmig.2017.03.016] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2016] [Revised: 03/17/2017] [Accepted: 03/20/2017] [Indexed: 10/19/2022]
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Chaudhary MA, Scully R, Jiang W, Chowdhury R, Zogg CK, Sharma M, Ranjit A, Koehlmoos T, Haider AH, Schoenfeld AJ. Patterns of use and factors associated with early discontinuation of opioids following major trauma. Am J Surg 2017; 214:792-797. [PMID: 28619266 DOI: 10.1016/j.amjsurg.2017.05.013] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2017] [Revised: 05/12/2017] [Accepted: 05/29/2017] [Indexed: 10/19/2022]
Abstract
BACKGROUND Inappropriate use of prescription opioids is a growing public-health issue. We sought to estimate the proportion of traumatic injury patients using legal prescription opioids up to 1-year after hospitalization. METHODS We used 2006-2014 claims data from TRICARE insurance to identify adults hospitalized secondary to trauma between 2007 and 2013. Prescription opioid use was evaluated for one-year post-discharge. Risk-adjusted Cox Proportional-hazards models were used to evaluate predictors of opioid discontinuation. RESULTS Only 1% of patients sustained legal prescription opioid use at 1-year following trauma. Lower socioeconomic status (HR 0.92, 95% CI 0.87-0.98) and higher injury severity (HR 0.88, 95% CI 0.84-0.91) were associated with sustained use. Younger patients (HR 1.12, 95% CI 1.04-1.21) and Black patients (HR 1.09, 95% CI 1.04-1.15) were found to have a higher likelihood of opioid discontinuation. CONCLUSIONS In this population, adult patients who sustained trauma were not at high risk of sustained legal prescription opioid use.
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Affiliation(s)
- Muhammad Ali Chaudhary
- Center for Surgery and Public Health, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School and Harvard T. H. Chan School of Public Health, Boston, MA, USA
| | - Rebecca Scully
- Center for Surgery and Public Health, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School and Harvard T. H. Chan School of Public Health, Boston, MA, USA
| | - Wei Jiang
- Center for Surgery and Public Health, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School and Harvard T. H. Chan School of Public Health, Boston, MA, USA
| | - Ritam Chowdhury
- Center for Surgery and Public Health, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School and Harvard T. H. Chan School of Public Health, Boston, MA, USA
| | - Cheryl K Zogg
- Center for Surgery and Public Health, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School and Harvard T. H. Chan School of Public Health, Boston, MA, USA
| | - Meesha Sharma
- Center for Surgery and Public Health, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School and Harvard T. H. Chan School of Public Health, Boston, MA, USA
| | - Anju Ranjit
- Center for Surgery and Public Health, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School and Harvard T. H. Chan School of Public Health, Boston, MA, USA
| | - Tracey Koehlmoos
- Uniformed Services University of the Health Sciences, Bethesda, MD, USA
| | - Adil H Haider
- Center for Surgery and Public Health, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School and Harvard T. H. Chan School of Public Health, Boston, MA, USA
| | - Andrew J Schoenfeld
- Center for Surgery and Public Health, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School and Harvard T. H. Chan School of Public Health, Boston, MA, USA; Department of Orthopedic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.
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