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John BV, Amoli MM, Evon DM, Wong R, Dahman B. Hepatitis delta testing trends in a US national cohort: An analysis of patient and provider-level predictive factors. Hepatol Commun 2024; 8:e0401. [PMID: 38619425 PMCID: PMC11019823 DOI: 10.1097/hc9.0000000000000401] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2023] [Accepted: 01/29/2024] [Indexed: 04/16/2024] Open
Abstract
BACKGROUND The low prevalence of HDV infection in the United States could be attributed to insufficient testing rate, which can result in an underestimation of the true burden of HDV. The primary objective of this study is to quantify the prevalence of and factors associated with HDV antibody (anti-HDV) or RNA testing, among participants with positive HBsAg in the Veterans Health Administration (VHA). METHODS We conducted a retrospective cohort study of participants who tested positive for HBsAg between January 2000 and December 2022 within the VHA. We identified those who were tested for HDV, and patient and provider-level factors associated with HDV testing. RESULTS Of 41,658 participants with positive HBsAg who had follow-up, 4438 (10.7%) were tested at least once for HDV, of which 135 (3.0%) were positive. Participants in the Northeast (adjusted odds ratio [aOR]: 1.30, 95% CI: 1.17-1.44, p<0.001), and receiving hepatology care (aOR: 1.38, 95% CI: 1.24-1.54, p<0.001) were more likely, while those in the Midwest (aOR: 0.69, 95% CI: 0.60-0.79, p<0.001), under the care of a primary care provider (aOR: 0.61, 95% CI: 0.50-0.74, p<0.001), Blacks (aOR: 0.85, 95% CI: 0.77-0.94, p=0.001), participants who were HCV antibody-positive (aOR: 0.89, 95% CI: 0.81-0.99, p=0.03), and participants who were HIV-positive (aOR: 0.80, 95% CI: 0.71-0.90, p<0.001) were less likely to be tested for HDV. CONCLUSIONS HDV screening rates in the VHA remain low overall. Participants who are Black, living in the Midwest, patients who are HIV-positive, and patients who are HCV-positive are less likely to be tested for HDV. These results suggest that risk-based screening strategies are ineffective in the VHA and highlight the need for refining testing strategies to increase HDV screening rates.
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Affiliation(s)
- Binu V. John
- Department of Medicine, Division of Gastroenterology and Hepatology, Miami VA Medical System, Miami, Florida, USA
- Division of Medical Education, University of Miami Miller School of Medicine, Miami, Florida, USA
| | | | - Donna M. Evon
- Department of Medicine, Division of Gastroenterology and Hepatology, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Robert Wong
- Division of Gastroenterology and Hepatology, Palo Alto VA Health System, Alto, California, USA
- Division of Gastroenterology, Stanford University, Palo Alto, California, USA
| | - Bassam Dahman
- Department of Health Behavior and Policy, Virginia Commonwealth University, Richmond, Virginia, USA
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Mujwara D, Kelvin EA, Dahman B, George G, Nixon D, Adera T, Mwai E, Kimmel AD. The economic costs and cost-effectiveness of HIV self-testing among truck drivers in Kenya. Health Policy Plan 2024; 39:355-362. [PMID: 38441272 PMCID: PMC11005835 DOI: 10.1093/heapol/czae013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2022] [Revised: 02/06/2024] [Accepted: 02/28/2024] [Indexed: 04/11/2024] Open
Abstract
HIV status awareness is critical for ending the HIV epidemic but remains low in high-HIV-risk and hard-to-reach sub-populations. Targeted, efficient interventions are needed to improve HIV test-uptake. We examined the incremental cost-effectiveness of offering the choice of self-administered oral HIV-testing (HIVST-Choice) compared with provider-administered testing only [standard-of-care (SOC)] among long-distance truck drivers. Effectiveness data came from a randomized-controlled trial conducted at two roadside wellness clinics in Kenya (HIVST-Choice arm, n = 150; SOC arm, n = 155). Economic cost data came from the literature, reflected a societal perspective and were reported in 2020 international dollars (I$), a hypothetical currency with equivalent purchasing power as the US dollar. Generalized Poisson and linear gamma regression models were used to estimate effectiveness and incremental costs, respectively; incremental effectiveness was reported as the number of long-distance truck drivers needing to receive HIVST-Choice for an additional HIV test-uptake. We calculated the incremental cost-effectiveness ratio (ICER) of HIVST-Choice compared with SOC and estimated 95% confidence intervals (CIs) using non-parametric bootstrapping. Uncertainty was assessed using deterministic sensitivity analysis and the cost-effectiveness acceptability curve. HIV test-uptake was 23% more likely for HIVST-Choice, with six individuals needing to be offered HIVST-Choice for an additional HIV test-uptake. The mean per-patient cost was nearly 4-fold higher in HIVST-Choice (I$39.28) versus SOC (I$10.80), with an ICER of I$174.51, 95% CI [165.72, 194.59] for each additional test-uptake. HIV self-test kit and cell phone service costs were the main drivers of the ICER, although findings were robust even at highest possible costs. The probability of cost-effectiveness approached 1 at a willingness-to-pay of I$200 for each additional HIV test-uptake. HIVST-Choice improves HIV-test-uptake among truck drivers at low willingness-to-pay thresholds, suggesting that HIV self-testing is an efficient use of resources. Policies supporting HIV self-testing in similar high risk, hard-to-reach sub-populations may expedite achievement of international targets.
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Affiliation(s)
- Deo Mujwara
- Department of Health Policy, Virginia Commonwealth University, 830 East Main Street, Richmond, VA 23298, USA
- Analysis Group, Inc, 111 Huntington Ave 4th floor, Boston, MA 02199, USA
| | - Elizabeth A Kelvin
- Department of Epidemiology and Biostatistics & CUNY Institute for Implementation Science in Population Health, City University of New York, 205 East 42nd Street, New York, NY 10017, USA
| | - Bassam Dahman
- Department of Health Policy, Virginia Commonwealth University, 830 East Main Street, Richmond, VA 23298, USA
| | - Gavin George
- Health Economics and HIV and AIDS Research Division, University of KwaZulu-Natal, Westville Campus, Private Bag X54001, Durban 4000, South Africa
| | - Daniel Nixon
- Department of Internal Medicine, Division of Infectious Diseases, Virginia Commonwealth University, 1200 E Broad St, Richmond, VA 23219, USA
| | - Tilahun Adera
- Department of Family Medicine and Population Health, Division of Epidemiology, 1200 E. Broad Street, Richmond, VA 23298, USA
| | - Eva Mwai
- North Star Alliance, 8 Silanga Road, Nairobi, Kenya
| | - April D Kimmel
- Department of Health Policy, Virginia Commonwealth University, 830 East Main Street, Richmond, VA 23298, USA
- Department of Internal Medicine, Division of Infectious Diseases, Virginia Commonwealth University, 1200 E Broad St, Richmond, VA 23219, USA
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Chin A, Bastaich DR, Dahman B, Kaplan DE, Taddei TH, John BV. Refractory hepatic hydrothorax is associated with increased mortality with death occurring at lower MELD-Na compared to cirrhosis and refractory ascites. Hepatology 2024; 79:844-856. [PMID: 37625139 DOI: 10.1097/hep.0000000000000577] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2023] [Accepted: 08/15/2023] [Indexed: 08/27/2023]
Abstract
BACKGROUND AND AIMS Although refractory hepatic hydrothorax (RH) is a serious complication of cirrhosis, waitlisted patients do not receive standardized Model for End-stage Liver Disease (MELD) exemption because of inadequate evidence suggesting mortality above biochemical MELD. This study aimed to examine liver-related death (LRD) associated with RH compared to refractory ascites (RA). APPROACH AND RESULTS This was a retrospective cohort study of Veterans with cirrhosis. Eligibility criteria included participants with RH or RA, followed from their first therapeutic thoracentesis/second paracentesis until death or transplantation. The primary outcome was LRD with non-LRD or transplantation as competing risk. Of 2552 patients with cirrhosis who underwent therapeutic thoracentesis/paracentesis, 177 met criteria for RH and 422 for RA. RH was associated with a significantly higher risk of LRD (adjusted HR [aHR] 4.63, 95% CI 3.31-6.48) than RA overall and within all MELD-sodium (MELD-Na) strata (<10 aHR 4.08, 95% CI 2.30-7.24, 10-14.9 aHR 5.68, 95% CI 2.63-12.28, 15-24.9 aHR 4.14, 95% CI 2.34-7.34, ≥25 aHR 7.75, 95% CI 2.99-20.12). LRD was higher among participants requiring 1 (aHR 3.54, 95% CI 2.29-5.48), 2-3 (aHR 4.39, 95% CI 2.91-6.63), and ≥4 (aHR 7.89, 95% CI 4.82-12.93) thoracenteses relative to RA. Although participants with RH and RA had similar baseline MELD-Na, LRD occurred in RH versus RA at a lower MELD-Na (16.5 vs. 21.82, p =0.002) but higher MELD 3.0 (27.85 vs. 22.48, p <0.0001). CONCLUSIONS RH was associated with higher risk of LRD than RA at equivalent MELD-Na. By contrast, MELD 3.0 may better predict risk of LRD in RH.
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Affiliation(s)
- Allison Chin
- Herbert Wertheim College of Medicine, Florida International University, Miami, Florida, USA
| | - Dustin R Bastaich
- Department of Biostatistics, Health Behavior and Policy, Virginia Commonwealth University, Richmond, Virginia, USA
| | - Bassam Dahman
- Department of Health Behavior and Policy, Virginia Commonwealth University, Richmond, Virginia, USA
| | - David E Kaplan
- Division of Gastroenterology and Hepatology, University of Pennsylvania, Corporal Michael J. Crescenz VA Medical Center, Philadelphia, Pennsylvania, USA
| | - Tamar H Taddei
- Section of Digestive Diseases, Yale School of Medicine, New Haven, Connecticut, USA
- VA Connecticut Healthcare System, West Haven, Connecticut, USA
| | - Binu V John
- Division of Gastroenterology and Hepatology, Miami VA Medical System, Miami, Florida, USA
- Division of Medical Education, University of Miami Miller School of Medicine, Miami, Florida, USA
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John BV, Dang Y, Kaplan DE, Jou JH, Taddei TH, Spector SA, Martin P, Bastaich DR, Chao HH, Dahman B. Liver Stiffness Measurement and Risk Prediction of Hepatocellular Carcinoma After HCV Eradication in Veterans With Cirrhosis. Clin Gastroenterol Hepatol 2024; 22:778-788.e7. [PMID: 38061410 PMCID: PMC10960676 DOI: 10.1016/j.cgh.2023.11.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2023] [Revised: 11/05/2023] [Accepted: 11/17/2023] [Indexed: 01/04/2024]
Abstract
BACKGROUND & AIMS Patients with cirrhosis secondary to chronic hepatitis C virus (HCV) are at risk for hepatocellular carcinoma (HCC) despite a sustained virological response (SVR). We examined whether post-SVR liver stiffness measurement (LSM) could be used to stratify HCC risk. METHODS This was a retrospective cohort study of 1850 participants identified from the Veterans Health Administration, with HCV cirrhosis and SVR, followed up over 5099 person-years, from the time of post-SVR elastography until death, HCC, or the end of the study. RESULTS The risk of HCC increased by 3% with every 1-kPa increase in LSM (adjusted hazard ratio [aHR], 1.03, 95% confidence interval [CI], 1.01-1.04; P < .001) and decreased with the number of years from SVR (aHR, 0.79; 95% CI, 0.70-0.90; P = .0003). The adjusted annual risk of HCC was 2.03% among participants with post-SVR LSM <10 kPa, 2.48% in LSM 10-14.9 kPa (aHR, 1.71; 95% CI, 1.01-2.88; P = .046), 3.22% for LSM 15-19.9 kPa (aHR, 1.59; 95% CI, 0.78-3.20; P = .20), 5.07% among LSM 20-24.9 kPa (aHR, 2.55; 95% CI, 1.30-5.01; P = .01), and 5.44% in LSM ≥25 kPa (aHR, 3.03; 95% CI, 1.74-5.26; P < .0001). The adjusted annual risk of HCC was < 0.4% in participants with LSM <5 kPa and without diabetes mellitus. CONCLUSIONS LSM predicts rates of HCC in patients with HCV cirrhosis after SVR at multiple cutoff levels and offers a single test to predict portal hypertension-related complications and HCC. Patients with LSM <5 kPa in the absence of diabetes mellitus had a low risk of HCC in which surveillance could be discontinued.
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Affiliation(s)
- Binu V John
- Division of Gastroenterology and Hepatology, Miami VA Medical System, Miami, Florida; Division of Digestive Health and Liver Diseases, University of Miami Miller School of Medicine, Miami, Florida.
| | - Yangyang Dang
- Department of Health Behavior and Policy, Virginia Commonwealth University, Richmond, Virginia
| | - David E Kaplan
- Division of Gastroenterology and Hepatology, University of Pennsylvania and Philadelphia VA Medical Center, Philadelphia, Pennsylvania
| | - Janice H Jou
- Division of Gastroenterology and Hepatology, Portland VA Medical Center and Oregon Health University, Portland, Oregon
| | - Tamar H Taddei
- Section of Digestive Diseases, Yale School of Medicine and VA Connecticut Healthcare System, West Haven, Connecticut
| | - Seth A Spector
- Department of Surgery, Miami VA Medical System, University of Miami Miller School of Medicine, Miami, Florida
| | - Paul Martin
- Division of Digestive Health and Liver Diseases, University of Miami Miller School of Medicine, Miami, Florida
| | - Dustin R Bastaich
- Department of Health Behavior and Policy, Virginia Commonwealth University, Richmond, Virginia
| | - Hann-Hsiang Chao
- Department of Radiation Oncology, Central Virginia Health System and Virginia Commonwealth University, Richmond, Virginia
| | - Bassam Dahman
- Department of Health Behavior and Policy, Virginia Commonwealth University, Richmond, Virginia
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Preston MA, Amoli MM, Chukmaitov AS, Krist AH, Dahman B. The impact of the affordable care act and Medicaid expansion on colorectal cancer screening: Evidence from the 5th year of Medicaid expansion. Cancer Med 2024; 13:e7054. [PMID: 38591114 PMCID: PMC11002632 DOI: 10.1002/cam4.7054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2023] [Revised: 02/05/2024] [Accepted: 02/16/2024] [Indexed: 04/10/2024] Open
Abstract
BACKGROUND Colorectal cancer screening rates remain suboptimal, particularly among low-income populations. Our objective was to evaluate the long-term effects of Medicaid expansion on colorectal cancer screening. DESIGN, SETTING, AND PARTICIPANTS This cross-sectional study analyzed data from 354,384 individuals aged 50-64 with an income below 400% of the federal poverty level (FPL), who participated in the Behavioral Risk Factors Surveillance System from 2010 to 2018. A difference-in-difference analysis was employed to estimate the effect of Medicaid expansion on colorectal cancer screening. Subgroup analyses were conducted for individuals with income up to 138% of the FPL and those with income between 139% and 400% of the FPL. The effect of Medicaid expansion on colorectal cancer screening was examined during the early, mid, and late expansion periods. MAIN OUTCOMES AND MEASURES The primary outcome was the likelihood of receiving colorectal cancer screening for low-income adults aged 50-64. RESULTS Medicaid expansion was associated with a significant 1.7 percentage point increase in colorectal cancer screening rates among adults aged 50-64 with income below 400% of the FPL (p < 0.05). A significant 2.9 percentage point increase in colorectal cancer screening was observed for those with income up to 138% the FPL (p < 0.05), while a 1.5 percentage point increase occurred for individuals with income between 139% and 400% of the FPL. The impact of Medicaid expansion on colorectal cancer screening varied based on income levels and displayed a time lag for newly eligible beneficiaries. CONCLUSIONS Medicaid expansion was found to be associated with increased colorectal cancer screening rates among low-income individuals aged 50-64. The observed variations in impact based on income levels and the time lag for newly eligible beneficiaries receiving colorectal cancer screening highlight the need for further research and precision public health strategies to maximize the benefits of Medicaid expansion on colorectal cancer screening rates.
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Affiliation(s)
- Michael A. Preston
- School of Population Health, Department of Health Behavior and PolicyVirginia Commonwealth UniversityRichmondVirginiaUSA
- Massey Cancer Center, Health Equity and Disparities ResearchVirginia Commonwealth UniversityRichmondVirginiaUSA
- Department of Pharmacy PracticePurdue UniversityWest LafayetteIndianaUSA
| | - Mahmoud Manouchehri Amoli
- School of Population Health, Department of Health Behavior and PolicyVirginia Commonwealth UniversityRichmondVirginiaUSA
| | - Askar S. Chukmaitov
- School of Population Health, Department of Health Behavior and PolicyVirginia Commonwealth UniversityRichmondVirginiaUSA
| | - Alex H. Krist
- Department of Family Medicine and Population HealthVirginia Commonwealth UniversityRichmondVirginiaUSA
| | - Bassam Dahman
- School of Population Health, Department of Health Behavior and PolicyVirginia Commonwealth UniversityRichmondVirginiaUSA
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Bono RS, Pan Z, Dahman B, Deng Y, Kimmel AD. Urban-rural disparities in geographic accessibility to care for people living with HIV. AIDS Care 2023; 35:1844-1851. [PMID: 36369925 PMCID: PMC10175509 DOI: 10.1080/09540121.2022.2141186] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2022] [Accepted: 10/21/2022] [Indexed: 11/15/2022]
Abstract
In the United States, people living with HIV (PLWH) in rural areas fare worse along the HIV care continuum than their urban counterparts; this may be due in part to limited geographic access to care. We estimated drive time to care for PLWH, focusing on urban-rural differences. Adult Medicaid enrollees living with HIV and their usual care clinicians were identified using administrative claims data from 14 states (Medicaid Analytic eXtract, 2009-2012). We used geographic network analysis to calculate one-way drive time from the enrollee's ZIP code tabulation area centroid to their clinician's practice address, then examined urban-rural differences using bivariate statistics. Additional analyses included altering the definition of rurality; examining subsamples based on the state of residence, services received, and clinician specialty; and adjusting for individual and county characteristics. Across n = 49,596 PLWH, median drive time to care was 12.8 min (interquartile range 26.3). Median drive time for rural enrollees (43.6 (82.0)) was nearly four times longer than for urban enrollees (11.9 (20.6) minutes, p < 0.0001), and drive times exceeded one hour for 38% of rural enrollees (versus 12% of urban, p < 0.0001). Urban-rural disparities remained in all additional analyses. Sustained efforts to circumvent limited geographic access to care are critical for rural areas.
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Affiliation(s)
- Rose S. Bono
- Department of Health Behavior and Policy, Virginia Commonwealth University School of Medicine, Richmond, Virginia, USA
| | - Zhongzhe Pan
- Department of Health Behavior and Policy, Virginia Commonwealth University School of Medicine, Richmond, Virginia, USA
| | - Bassam Dahman
- Department of Health Behavior and Policy, Virginia Commonwealth University School of Medicine, Richmond, Virginia, USA
| | - Yangyang Deng
- Department of Health Behavior and Policy, Virginia Commonwealth University School of Medicine, Richmond, Virginia, USA
| | - April D. Kimmel
- Department of Health Behavior and Policy, Virginia Commonwealth University School of Medicine, Richmond, Virginia, USA
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John BV, Bastaich DR, Ferreira RD, Doshi A, Taddei TH, Kaplan DE, Spector S, Deng Y, Dahman B. COVID-19 vaccine effectiveness and community prevalence of Alpha, Delta and Omicron variants in patients with cirrhosis. Gut 2023; 72:1800-1802. [PMID: 36562753 DOI: 10.1136/gutjnl-2022-327799] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2022] [Accepted: 08/29/2022] [Indexed: 12/24/2022]
Affiliation(s)
- Binu V John
- Gastroenterology and Hepatology, University of Miami, Miami, Florida, USA
- Gastroenterology and Hepatology, Miami VA Healthcare System, Miami, Florida, USA
| | - Dustin R Bastaich
- Department of Health Behavior and Policy, Virginia Commonwealth University, Richmond, Virginia, USA
| | - Raphaella D Ferreira
- Gastroenterology and Hepatology, Miami VA Healthcare System, Miami, Florida, USA
| | - Akash Doshi
- Miller School of Medicine, University of Miami, Miami, Florida, USA
| | - Tamar H Taddei
- Medicine, VA Connecticut Health System West Haven Campus, West Haven, Connecticut, USA
| | - David E Kaplan
- Gastroenterology and Hepatology, Hospital of the Inversity of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Seth Spector
- Department of Surgery, University of Miami, Coral Gables, Florida, USA
- Department of Surgery, Bruce W Carter Department of Veterans Affairs Medical Center, Miami, Florida, USA
| | - Yangyang Deng
- Department of Health Behavior and Policy, Virginia Commonwealth University, Richmond, Virginia, USA
| | - Bassam Dahman
- Department of Health Behavior and Policy, Virginia Commonwealth University, Richmond, Virginia, USA
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John BV, Bastaich D, Webb G, Brevini T, Moon A, Ferreira RD, Chin AM, Kaplan DE, Taddei TH, Serper M, Mahmud N, Deng Y, Chao HH, Sampaziotis F, Dahman B. Ursodeoxycholic acid is associated with a reduction in SARS-CoV-2 infection and reduced severity of COVID-19 in patients with cirrhosis. J Intern Med 2023; 293:636-647. [PMID: 37018129 DOI: 10.1111/joim.13630] [Citation(s) in RCA: 11] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/06/2023]
Abstract
BACKGROUND AND AIMS Studies have demonstrated that reducing farnesoid X receptor activity with ursodeoxycholic acid (UDCA) downregulates angiotensin-converting enzyme in human lung, intestinal and cholangiocytes organoids in vitro, in human lungs and livers perfused ex situ, reducing internalization of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) into the host cell. This offers a potential novel target against coronavirus disease 2019 (COVID-19). The objective of our study was to compare the association between UDCA exposure and SARS-CoV-2 infection, as well as varying severities of COVID-19, in a large national cohort of participants with cirrhosis. METHODS In this retrospective cohort study among participants with cirrhosis in the Veterans Outcomes and Costs Associated with Liver cohort, we compared participants with exposure to UDCA, with a propensity score (PS) matched group of participants without UDCA exposure, matched for clinical characteristics, and vaccination status. The outcomes included SARS-CoV-2 infection, symptomatic, at least moderate, severe, or critical COVID-19, and COVID-19-related death. RESULTS We compared 1607 participants with cirrhosis who were on UDCA, with 1607 PS-matched controls. On multivariable logistic regression, UDCA exposure was associated with reduced odds of developing SARS-CoV-2 infection (adjusted odds ratio [aOR] 0.54, 95% confidence interval [CI] 0.41-0.71, p < 0.0001). Among patients who developed COVID-19, UDCA use was associated with reduced disease severity, including symptomatic COVID-19 (aOR 0.54, 95% CI 0.39-0.73, p < 0.0001), at least moderate COVID-19 (aOR 0.51, 95% CI 0.32-0.81, p = 0.005), and severe or critical COVID-19 (aOR 0.48, 95% CI 0.25-0.94, p = 0.03). CONCLUSIONS In participants with cirrhosis, UDCA exposure was associated with both a decrease in SARS-CoV-2 infection, and reduction in symptomatic, at least moderate, and severe/critical COVID-19.
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Affiliation(s)
- Binu V John
- Division of Gastroenterology and Hepatology, Miami VA Medical System, Miami, Florida, USA
- Division of Digestive Health and Liver Diseases, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Dustin Bastaich
- Department of Health Behavior and Policy, Virginia Commonwealth University, Richmond, Virginia, USA
| | - Gwilym Webb
- Cambridge Liver Unit, Cambridge University Hospital, NHS Foundation Trust, Cambridge, UK
| | - Teresa Brevini
- Wellcome-MRC Cambridge Stem Cell Institute, Cambridge, UK
| | - Andrew Moon
- Division of Gastroenterology and Hepatology, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Raphaella D Ferreira
- Division of Gastroenterology and Hepatology, Miami VA Medical System, Miami, Florida, USA
| | - Allison M Chin
- Herbert Wertheim Florida International University, Miami, Florida, USA
| | - David E Kaplan
- Division of Gastroenterology and Hepatology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Section of Gastroenterology and Hepatology, Corporal Michael J. Crescenz VA Medical Center, Philadelphia, Pennsylvania, USA
| | - Tamar H Taddei
- Section of Digestive Diseases, Yale School of Medicine, New Haven, Connecticut, USA
- Section of Gastroenterology, VA Connecticut Healthcare System, West Haven, Connecticut, USA
| | - Marina Serper
- Division of Gastroenterology and Hepatology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Nadim Mahmud
- Division of Gastroenterology and Hepatology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Yangyang Deng
- Department of Health Behavior and Policy, Virginia Commonwealth University, Richmond, Virginia, USA
| | - Hann-Hsiang Chao
- Department of Radiation Oncology, Central Virginia Health System, Richmond, Virginia, USA
| | - Fotios Sampaziotis
- Wellcome-MRC Cambridge Stem Cell Institute, Cambridge, UK
- Cambridge Liver Unit, Cambridge University Hospital, NHS Foundation Trust, Cambridge, UK
| | - Bassam Dahman
- Department of Health Behavior and Policy, Virginia Commonwealth University, Richmond, Virginia, USA
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Edmonds MC, Dahman B, Kim SJ, McGuire KP, Sheppard VB. Surveillance Mammography Behaviors in Black and White Breast Cancer Survivors: Behavioral Risk Factors and Surveillance System, 2016. BMC Womens Health 2023; 23:148. [PMID: 36997881 PMCID: PMC10061852 DOI: 10.1186/s12905-023-02246-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2022] [Accepted: 02/24/2023] [Indexed: 04/01/2023] Open
Abstract
BACKGROUND Surveillance mammography is recommended annually for early detection of disease relapse among breast cancer survivors; yet Black women have poorer national rates of surveillance mammography compared to White women. Factors that influence racial disparities in surveillance mammography rates are poorly understood. The purpose of this study is to evaluate the contribution of health care access, socioeconomic status, and perceived health status on adherence to surveillance mammography among breast cancer survivors. METHODS This is a secondary analysis of a cross-sectional survey among Black and White women ≥ 18 years, who reported a breast cancer diagnosis and completed breast surgery and adjuvant treatment from the 2016 Behavioral Risk Factor Surveillance System National Survey (BRFSS). Bivariate associations (chi-squared, t-test) for independent variables (e.g., health insurance, marital status) were analyzed with adherence to nationally recommended surveillance guidelines defined as two levels: adherent (received a mammogram in the last 12 months), vs. non- adherent ("received a mammogram in the last 2-5 years, 5 or more years or unsure). Multivariable logistic regression models were used to evaluate the relationship between study variables with adherence, while adjusting for potential confounders. RESULTS Of 963 breast cancer survivors, 91.7% were White women with an average age of 65. 71.7% reported a surveillance mammogram in the last 12 months, while 28.2% did not. Diagnosed > 5 years (p < 0.001); not having a routine checkup visit within 12 months (p = 0.045); and not seeing a doctor when needed due to cost (p = 0.026), were significantly related to survivor's non-adherence to surveillance mammography guidelines. A significant interaction was found between race and residential area (p < 0.001). Compared to White women, Black women living in metropolitan/suburban residential areas were more likely to receive surveillance guidelines (OR:3.77;95% CI: 1.32-10.81); however Black women living in non-metropolitan areas were less likely to receive a surveillance mammogram compared to White women living in non-metropolitan areas (OR: 0.04; 95% CI: 0.00-0.50). CONCLUSION Findings from our study further explain the impact of socioeconomic disparities on racial differences in the use of surveillance mammography among breast cancer survivors. Black women living in non-metropolitan counties are an important subgroup for future research and screening and navigation interventions.
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Affiliation(s)
- Megan C Edmonds
- Division of General Internal Medicine, Icahn School of Medicine at Mount Sinai, 17 E. 102 St, New York, NY, USA.
| | - Bassam Dahman
- Department of Health Behavior and Policy, School of Medicine, Virginia Commonwealth University, Richmond, VA, USA
| | - Sunny Jung Kim
- Department of Health Behavior and Policy, School of Medicine, Virginia Commonwealth University, Richmond, VA, USA
- VCU Massey Cancer Center, Richmond, VA, USA
| | - Kandace P McGuire
- VCU Massey Cancer Center, Richmond, VA, USA
- Department of Surgery, VCU Massey Cancer Center, Richmond, VA, USA
| | - Vanessa B Sheppard
- Department of Health Behavior and Policy, School of Medicine, Virginia Commonwealth University, Richmond, VA, USA
- VCU Massey Cancer Center, Richmond, VA, USA
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10
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Brevini T, Maes M, Webb GJ, John BV, Fuchs CD, Buescher G, Wang L, Griffiths C, Brown ML, Scott WE, Pereyra-Gerber P, Gelson WTH, Brown S, Dillon S, Muraro D, Sharp J, Neary M, Box H, Tatham L, Stewart J, Curley P, Pertinez H, Forrest S, Mlcochova P, Varankar SS, Darvish-Damavandi M, Mulcahy VL, Kuc RE, Williams TL, Heslop JA, Rossetti D, Tysoe OC, Galanakis V, Vila-Gonzalez M, Crozier TWM, Bargehr J, Sinha S, Upponi SS, Fear C, Swift L, Saeb-Parsy K, Davies SE, Wester A, Hagström H, Melum E, Clements D, Humphreys P, Herriott J, Kijak E, Cox H, Bramwell C, Valentijn A, Illingworth CJR, Dahman B, Bastaich DR, Ferreira RD, Marjot T, Barnes E, Moon AM, Barritt AS, Gupta RK, Baker S, Davenport AP, Corbett G, Gorgoulis VG, Buczacki SJA, Lee JH, Matheson NJ, Trauner M, Fisher AJ, Gibbs P, Butler AJ, Watson CJE, Mells GF, Dougan G, Owen A, Lohse AW, Vallier L, Sampaziotis F. FXR inhibition may protect from SARS-CoV-2 infection by reducing ACE2. Nature 2023; 615:134-142. [PMID: 36470304 PMCID: PMC9977684 DOI: 10.1038/s41586-022-05594-0] [Citation(s) in RCA: 93] [Impact Index Per Article: 93.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2021] [Accepted: 11/23/2022] [Indexed: 12/12/2022]
Abstract
Preventing SARS-CoV-2 infection by modulating viral host receptors, such as angiotensin-converting enzyme 2 (ACE2)1, could represent a new chemoprophylactic approach for COVID-19 that complements vaccination2,3. However, the mechanisms that control the expression of ACE2 remain unclear. Here we show that the farnesoid X receptor (FXR) is a direct regulator of ACE2 transcription in several tissues affected by COVID-19, including the gastrointestinal and respiratory systems. We then use the over-the-counter compound z-guggulsterone and the off-patent drug ursodeoxycholic acid (UDCA) to reduce FXR signalling and downregulate ACE2 in human lung, cholangiocyte and intestinal organoids and in the corresponding tissues in mice and hamsters. We show that the UDCA-mediated downregulation of ACE2 reduces susceptibility to SARS-CoV-2 infection in vitro, in vivo and in human lungs and livers perfused ex situ. Furthermore, we reveal that UDCA reduces the expression of ACE2 in the nasal epithelium in humans. Finally, we identify a correlation between UDCA treatment and positive clinical outcomes after SARS-CoV-2 infection using retrospective registry data, and confirm these findings in an independent validation cohort of recipients of liver transplants. In conclusion, we show that FXR has a role in controlling ACE2 expression and provide evidence that modulation of this pathway could be beneficial for reducing SARS-CoV-2 infection, paving the way for future clinical trials.
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Affiliation(s)
- Teresa Brevini
- Wellcome-MRC Cambridge Stem Cell Institute, Cambridge, UK.
| | - Mailis Maes
- Cambridge Institute of Therapeutic Immunology & Infectious Disease (CITIID), Department of Medicine, University of Cambridge, Cambridge, UK
| | - Gwilym J Webb
- Cambridge Liver Unit, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Binu V John
- Division of Gastroenterology and Hepatology, University of Miami and Miami VA Health System, Miami, FL, USA
| | - Claudia D Fuchs
- Hans Popper Laboratory of Molecular Hepatology, Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
| | - Gustav Buescher
- Department of Medicine, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
| | - Lu Wang
- Transplant and Regenerative Medicine Laboratory, Translational and Clinical Research Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, UK
| | - Chelsea Griffiths
- Transplant and Regenerative Medicine Laboratory, Translational and Clinical Research Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, UK
| | - Marnie L Brown
- Transplant and Regenerative Medicine Laboratory, Translational and Clinical Research Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, UK
| | - William E Scott
- Transplant and Regenerative Medicine Laboratory, Translational and Clinical Research Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, UK
| | - Pehuén Pereyra-Gerber
- Cambridge Institute of Therapeutic Immunology & Infectious Disease (CITIID), Department of Medicine, University of Cambridge, Cambridge, UK
| | - William T H Gelson
- Cambridge Liver Unit, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
- Department of Medicine, University of Cambridge, Cambridge, UK
| | | | - Scott Dillon
- Wellcome-MRC Cambridge Stem Cell Institute, Cambridge, UK
| | | | - Jo Sharp
- Centre of Excellence in Long-acting Therapeutics (CELT), Department of Pharmacology and Therapeutics, Institute of Systems, Molecular and Integrative Biology, University of Liverpool, Liverpool, UK
| | - Megan Neary
- Centre of Excellence in Long-acting Therapeutics (CELT), Department of Pharmacology and Therapeutics, Institute of Systems, Molecular and Integrative Biology, University of Liverpool, Liverpool, UK
| | - Helen Box
- Centre of Excellence in Long-acting Therapeutics (CELT), Department of Pharmacology and Therapeutics, Institute of Systems, Molecular and Integrative Biology, University of Liverpool, Liverpool, UK
| | - Lee Tatham
- Centre of Excellence in Long-acting Therapeutics (CELT), Department of Pharmacology and Therapeutics, Institute of Systems, Molecular and Integrative Biology, University of Liverpool, Liverpool, UK
| | - James Stewart
- Department of Infection Biology and Microbiomes, Institute of Infection, Veterinary and Ecological Sciences, University of Liverpool, Liverpool, UK
| | - Paul Curley
- Centre of Excellence in Long-acting Therapeutics (CELT), Department of Pharmacology and Therapeutics, Institute of Systems, Molecular and Integrative Biology, University of Liverpool, Liverpool, UK
| | - Henry Pertinez
- Centre of Excellence in Long-acting Therapeutics (CELT), Department of Pharmacology and Therapeutics, Institute of Systems, Molecular and Integrative Biology, University of Liverpool, Liverpool, UK
| | - Sally Forrest
- Cambridge Institute of Therapeutic Immunology & Infectious Disease (CITIID), Department of Medicine, University of Cambridge, Cambridge, UK
| | - Petra Mlcochova
- Cambridge Institute of Therapeutic Immunology & Infectious Disease (CITIID), Department of Medicine, University of Cambridge, Cambridge, UK
- Division of Gastroenterology and Hepatology, University of Miami and Miami VA Health System, Miami, FL, USA
| | | | - Mahnaz Darvish-Damavandi
- Wellcome-MRC Cambridge Stem Cell Institute, Cambridge, UK
- Nuffield Department of Surgical Sciences, University of Oxford, Oxford, UK
| | - Victoria L Mulcahy
- Academic Department of Medical Genetics, University of Cambridge, Cambridge, UK
| | - Rhoda E Kuc
- Experimental Medicine and Immunotherapeutics, University of Cambridge, Addenbrooke's Hospital, Cambridge, UK
| | - Thomas L Williams
- Experimental Medicine and Immunotherapeutics, University of Cambridge, Addenbrooke's Hospital, Cambridge, UK
| | - James A Heslop
- Wellcome-MRC Cambridge Stem Cell Institute, Cambridge, UK
| | | | - Olivia C Tysoe
- Wellcome-MRC Cambridge Stem Cell Institute, Cambridge, UK
- Department of Surgery, University of Cambridge and NIHR Cambridge Biomedical Research Centre, Cambridge, UK
| | | | | | - Thomas W M Crozier
- Cambridge Institute of Therapeutic Immunology & Infectious Disease (CITIID), Department of Medicine, University of Cambridge, Cambridge, UK
| | - Johannes Bargehr
- Wellcome-MRC Cambridge Stem Cell Institute, Cambridge, UK
- Department of Medicine, University of Cambridge, Cambridge, UK
- Division of Cardiovascular Medicine, University of Cambridge, Cambridge, UK
| | - Sanjay Sinha
- Wellcome-MRC Cambridge Stem Cell Institute, Cambridge, UK
- Division of Cardiovascular Medicine, University of Cambridge, Cambridge, UK
| | - Sara S Upponi
- Department of Radiology, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Corrina Fear
- Department of Surgery, University of Cambridge and NIHR Cambridge Biomedical Research Centre, Cambridge, UK
| | - Lisa Swift
- Department of Surgery, University of Cambridge and NIHR Cambridge Biomedical Research Centre, Cambridge, UK
| | - Kourosh Saeb-Parsy
- Department of Surgery, University of Cambridge and NIHR Cambridge Biomedical Research Centre, Cambridge, UK
- Roy Calne Transplant Unit, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Susan E Davies
- Department of Histopathology, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Axel Wester
- Department of Medicine, Huddinge, Karolinska Institutet, Stockholm, Sweden
| | - Hannes Hagström
- Department of Medicine, Huddinge, Karolinska Institutet, Stockholm, Sweden
| | - Espen Melum
- Norwegian PSC Research Center, Department of Transplantation Medicine, Division of Surgery, Inflammatory Diseases and Transplantation, Oslo University Hospital, Rikshospitalet, Oslo, Norway
- Research Institute of Internal Medicine, Division of Surgery, Inflammatory Diseases and Transplantation, Oslo University Hospital, Rikshospitalet, Oslo, Norway
- Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway
- Section of Gastroenterology, Department of Transplantation Medicine, Division of Surgery, Inflammatory Diseases and Transplantation, Oslo University Hospital, Rikshospitalet, Oslo, Norway
- Hybrid Technology Hub Centre of Excellence, Institute of Basic Medical Sciences, Faculty of Medicine, University of Oslo, Oslo, Norway
| | | | | | - Jo Herriott
- Centre of Excellence in Long-acting Therapeutics (CELT), Department of Pharmacology and Therapeutics, Institute of Systems, Molecular and Integrative Biology, University of Liverpool, Liverpool, UK
| | - Edyta Kijak
- Centre of Excellence in Long-acting Therapeutics (CELT), Department of Pharmacology and Therapeutics, Institute of Systems, Molecular and Integrative Biology, University of Liverpool, Liverpool, UK
| | - Helen Cox
- Centre of Excellence in Long-acting Therapeutics (CELT), Department of Pharmacology and Therapeutics, Institute of Systems, Molecular and Integrative Biology, University of Liverpool, Liverpool, UK
| | - Chloe Bramwell
- Centre of Excellence in Long-acting Therapeutics (CELT), Department of Pharmacology and Therapeutics, Institute of Systems, Molecular and Integrative Biology, University of Liverpool, Liverpool, UK
| | - Anthony Valentijn
- Centre of Excellence in Long-acting Therapeutics (CELT), Department of Pharmacology and Therapeutics, Institute of Systems, Molecular and Integrative Biology, University of Liverpool, Liverpool, UK
| | - Christopher J R Illingworth
- MRC-University of Glasgow Centre for Virus Research, Glasgow, UK
- Department of Applied Mathematics and Theoretical Physics, University of Cambridge, Cambridge, UK
| | - Bassam Dahman
- Department of Health Behavior and Policy, Virginia Commonwealth University, Richmond, VA, USA
| | - Dustin R Bastaich
- Department of Health Behavior and Policy, Virginia Commonwealth University, Richmond, VA, USA
| | - Raphaella D Ferreira
- Division of Gastroenterology and Hepatology, University of Miami and Miami VA Health System, Miami, FL, USA
| | - Thomas Marjot
- Oxford Liver Unit, Translational Gastroenterology Unit, Oxford University Hospitals NHS Foundation Trust, University of Oxford, Oxford, UK
| | - Eleanor Barnes
- Oxford Liver Unit, Translational Gastroenterology Unit, Oxford University Hospitals NHS Foundation Trust, University of Oxford, Oxford, UK
| | - Andrew M Moon
- Division of Gastroenterology and Hepatology, University of North Carolina, Chapel Hill, NC, USA
| | - Alfred S Barritt
- Division of Gastroenterology and Hepatology, University of North Carolina, Chapel Hill, NC, USA
| | - Ravindra K Gupta
- Cambridge Institute of Therapeutic Immunology & Infectious Disease (CITIID), Department of Medicine, University of Cambridge, Cambridge, UK
- Department of Medicine, University of Cambridge, Cambridge, UK
| | - Stephen Baker
- Cambridge Institute of Therapeutic Immunology & Infectious Disease (CITIID), Department of Medicine, University of Cambridge, Cambridge, UK
| | - Anthony P Davenport
- Experimental Medicine and Immunotherapeutics, University of Cambridge, Addenbrooke's Hospital, Cambridge, UK
| | - Gareth Corbett
- Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Vassilis G Gorgoulis
- Department of Histology and Embryology, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
- Ninewells Hospital and Medical School, University of Dundee, Dundee, UK
- Biomedical Research Foundation, Academy of Athens, Athens, Greece
| | - Simon J A Buczacki
- Wellcome-MRC Cambridge Stem Cell Institute, Cambridge, UK
- Nuffield Department of Surgical Sciences, University of Oxford, Oxford, UK
| | - Joo-Hyeon Lee
- Wellcome-MRC Cambridge Stem Cell Institute, Cambridge, UK
- Department of Physiology, Development and Neuroscience, University of Cambridge, Cambridge, UK
| | - Nicholas J Matheson
- Cambridge Institute of Therapeutic Immunology & Infectious Disease (CITIID), Department of Medicine, University of Cambridge, Cambridge, UK
- Department of Medicine, University of Cambridge, Cambridge, UK
- Division of Gastroenterology and Hepatology, University of North Carolina, Chapel Hill, NC, USA
- NHS Blood and Transplant, Cambridge, UK
| | - Michael Trauner
- Hans Popper Laboratory of Molecular Hepatology, Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
| | - Andrew J Fisher
- Transplant and Regenerative Medicine Laboratory, Translational and Clinical Research Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, UK
| | - Paul Gibbs
- Department of Surgery, University of Cambridge and NIHR Cambridge Biomedical Research Centre, Cambridge, UK
- Roy Calne Transplant Unit, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Andrew J Butler
- Department of Surgery, University of Cambridge and NIHR Cambridge Biomedical Research Centre, Cambridge, UK
- Roy Calne Transplant Unit, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Christopher J E Watson
- Department of Surgery, University of Cambridge and NIHR Cambridge Biomedical Research Centre, Cambridge, UK
- Roy Calne Transplant Unit, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
- National Institute of Health Research (NIHR) Cambridge Biomedical Research Centre, and the NIHR Blood and Transplant Research Unit (BTRU) at the University of Cambridge in collaboration with Newcastle University and in partnership with NHS Blood and Transplant (NHSBT), Cambridge, UK
| | - George F Mells
- Cambridge Liver Unit, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
- Academic Department of Medical Genetics, University of Cambridge, Cambridge, UK
| | - Gordon Dougan
- Cambridge Institute of Therapeutic Immunology & Infectious Disease (CITIID), Department of Medicine, University of Cambridge, Cambridge, UK
| | - Andrew Owen
- Centre of Excellence in Long-acting Therapeutics (CELT), Department of Pharmacology and Therapeutics, Institute of Systems, Molecular and Integrative Biology, University of Liverpool, Liverpool, UK
| | - Ansgar W Lohse
- Department of Medicine, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
| | - Ludovic Vallier
- Wellcome-MRC Cambridge Stem Cell Institute, Cambridge, UK.
- Wellcome Sanger Institute, Hinxton, UK.
- Berlin Institute of Health (BIH), BIH Centre for Regenerative Therapies (BCRT), Charité-Universitätsmedizin Berlin, Berlin, Germany.
- Max Planck Institute for Molecular Genetics, Berlin, Germany.
| | - Fotios Sampaziotis
- Wellcome-MRC Cambridge Stem Cell Institute, Cambridge, UK.
- Cambridge Liver Unit, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK.
- Department of Medicine, University of Cambridge, Cambridge, UK.
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11
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Masiano SP, Kawende B, Ravelomanana NLR, Green TL, Dahman B, Thirumurthy H, Kimmel AD, Yotebieng M. Economic costs and cost-effectiveness of conditional cash transfers for the uptake of services for the prevention of vertical HIV transmissions in a resource-limited setting. Soc Sci Med 2023; 320:115684. [PMID: 36696797 PMCID: PMC9975037 DOI: 10.1016/j.socscimed.2023.115684] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2022] [Revised: 12/06/2022] [Accepted: 01/13/2023] [Indexed: 01/15/2023]
Abstract
BACKGROUND Prevention of mother-to-child transmission (PMTCT) is critical for halting the HIV epidemic. However, innovative approaches to improve PMTCT uptake may be resource-intensive. We examined the economic costs and cost-effectiveness of conditional cash transfers (CCTs) for the uptake of PMTCT services in the Democratic Republic of Congo. METHODS We leveraged data from a randomized controlled trial of CCTs (n = 216) versus standard PMTCT care alone (standard of care (SOC), n = 217). Economic cost data came from multiple sources, with costs analyzed from the societal perspective and reported in 2016 international dollars (I$). Effectiveness outcomes included PMTCT uptake (i.e., accepting all PMTCT visits and services) and retention (i.e., in HIV care at six weeks post-partum). Generalized estimating equations estimated effectiveness (relative risk) and incremental costs, with incremental effectiveness reported as the number of women needing CCTs for an additional PMTCT uptake or retention. We evaluated the cost-effectiveness of the CCTs at various levels of willingness-to-pay and assessed uncertainty using deterministic sensitivity analysis and cost-effectiveness acceptability curves. RESULTS Mean costs per participant were I$516 (CCTs) and I$431 (SOC), representing an incremental cost of I$85 (95% CI: 59, 111). PMTCT uptake was more likely for CCTs vs SOC (68% vs 53%, p < 0.05), with seven women needing CCTs for each additional PMTCT service uptake; twelve women needed CCTs for an additional PMTCT retention. The incremental cost-effectiveness of CCTs vs SOC was I$595 (95% CI: I$550, I$638) for PMTCT uptake and I$1028 (95% CI: I$931, I$1125) for PMTCT retention. CCTs would be an efficient use of resources if society's willingness-to-pay for an additional woman who takes up PMTCT services is at least I$640. In the worst-case scenario, the findings remained relatively robust. CONCLUSIONS Given the relatively low cost of the CCTs, policies supporting CCTs may decrease onward HIV transmission and expedite progress toward ending the epidemic.
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Affiliation(s)
- Steven P Masiano
- Department of Health Behavior and Policy, Virginia Commonwealth University School of Medicine, Richmond, VA, 23219, USA; Department of Quantitative Health Sciences, Lerner Research Institute, Cleveland Clinic, Cleveland, OH, 44195, USA.
| | - Bienvenu Kawende
- The University of Kinshasa, School of Public Health, Kinshasa, Democratic Republic of the Congo, The
| | - Noro Lantoniaina Rosa Ravelomanana
- The University of Kinshasa, School of Public Health, Kinshasa, Democratic Republic of the Congo, The; Albert Einstein College of Medicine, Department of Medicine, Division of General Internal Medicine, 3300 Kossuth Ave, Bronx, NY, 10467, USA
| | - Tiffany L Green
- Department of Health Behavior and Policy, Virginia Commonwealth University School of Medicine, Richmond, VA, 23219, USA; Departments of Population Health Sciences and Obstetrics and Gynecology, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Bassam Dahman
- Department of Health Behavior and Policy, Virginia Commonwealth University School of Medicine, Richmond, VA, 23219, USA
| | - Harsha Thirumurthy
- Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, USA; Center for Health Incentives and Behavioral Economics, University of Pennsylvania, USA
| | - April D Kimmel
- Department of Health Behavior and Policy, Virginia Commonwealth University School of Medicine, Richmond, VA, 23219, USA.
| | - Marcel Yotebieng
- The University of Kinshasa, School of Public Health, Kinshasa, Democratic Republic of the Congo, The; Albert Einstein College of Medicine, Department of Medicine, Division of General Internal Medicine, 3300 Kossuth Ave, Bronx, NY, 10467, USA
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12
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John BV, Dahman B. Reply. Hepatology 2023; 77:E14-E16. [PMID: 36054711 PMCID: PMC9538554 DOI: 10.1002/hep.32748] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2022] [Accepted: 08/21/2022] [Indexed: 01/13/2023]
Affiliation(s)
- Binu V. John
- Division of Gastroenterology and HepatologyMiami VA Health SystemMiamiFloridaUSA
- Division of Digestive Health and Liver DiseasesUniversity of Miami Miller School of MedicineMiamiFloridaUSA
| | - Bassam Dahman
- Department of Health Behavior and PolicyVirginia Commonwealth UniversityRichmondVirginiaUSA
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13
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Pan Z, Dahman B, Bono RS, Sabik LM, Belgrave FZ, Yerkes L, Nixon DE, Kimmel AD. Brief Report: Physician Reimbursement and Retention in HIV Care: Racial Disparities in the US South. J Acquir Immune Defic Syndr 2023; 92:1-5. [PMID: 36184773 PMCID: PMC9742342 DOI: 10.1097/qai.0000000000003105] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2022] [Accepted: 08/17/2022] [Indexed: 02/04/2023]
Abstract
BACKGROUND Retention in HIV care remains a national challenge. Addressing structural barriers to care may improve retention. We examined the association between physician reimbursement and retention in HIV care, including racial differences. METHODS We integrated person-level administrative claims (Medicaid Analytic eXtract, 2008-2012), state Medicaid-to-Medicare physician fee ratios (Urban Institute, 2008, 2012), and county characteristics for 15 Southern states plus District of Columbia. The fee ratio is a standardized measure of physician reimbursement capturing Medicaid relative to Medicare physician reimbursement across states. Generalized estimating equations assessed the association between the fee ratio and retention (≥2 care markers ≥90 days apart in a calendar year). Stratified analyses assessed racial differences. We varied definitions of retention, subsamples, and definitions of the fee ratio, including the fee ratio at parity. RESULTS The sample included 55,237 adult Medicaid enrollees with HIV (179,002 enrollee years). Enrollees were retained in HIV care for 76.6% of their enrollment years, with retention lower among non-Hispanic Black (76.1%) versus non-Hispanic White enrollees (81.3%, P < 0.001). A 10-percentage point increase in physician reimbursement was associated with 4% increased odds of retention (adjusted odds ratio 1.04, 95% confidence interval: 1.01 to 1.07). In stratified analyses, the positive, significant association occurred among non-Hispanic Black (1.08, 1.05-1.12) but not non-Hispanic White enrollees (0.87, 0.74-1.02). Findings were robust across sensitivity analyses. When the fee ratio reached parity, predicted retention increased significantly overall and for non-Hispanic Black enrollees. CONCLUSION Higher physician reimbursement may improve retention in HIV care, particularly among non-Hispanic Black individuals, and could be a mechanism to promote health equity.
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Affiliation(s)
- Zhongzhe Pan
- Department of Health Behavior and Policy, Virginia Commonwealth University, Richmond, Virginia, USA
| | - Bassam Dahman
- Department of Health Behavior and Policy, Virginia Commonwealth University, Richmond, Virginia, USA
| | - Rose S. Bono
- Department of Health Behavior and Policy, Virginia Commonwealth University, Richmond, Virginia, USA
| | - Lindsay M. Sabik
- Department of Health Policy and Management, University of Pittsburgh Graduate School of Public Health, Pittsburgh, Pennsylvania, USA
| | - Faye Z. Belgrave
- Department of Psychology, Virginia Commonwealth University, Richmond, Virginia, USA
| | - Lauren Yerkes
- Virginia Department of Health, Richmond, Virginia, USA
| | - Daniel E. Nixon
- Department of Internal Medicine, Division of Infectious Diseases, Virginia Commonwealth University, Richmond, Virginia, USA
| | - April D. Kimmel
- Department of Health Behavior and Policy, Virginia Commonwealth University, Richmond, Virginia, USA
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14
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John BV, Doshi A, Ferreira RD, Taddei TH, Kaplan DE, Spector SA, Deng Y, Bastaich D, Dahman B. Comparison of infection-induced and vaccine-induced immunity against COVID-19 in patients with cirrhosis. Hepatology 2023; 77:186-196. [PMID: 35712794 DOI: 10.1002/hep.32619] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2022] [Revised: 05/27/2022] [Accepted: 06/13/2022] [Indexed: 02/03/2023]
Abstract
BACKGROUND AND AIMS Immunity to SARS-CoV-2 can be infection or vaccine-induced. Cirrhosis is associated with vaccine hyporesponsiveness, but whether there is decreased immunity after SARS-CoV-2 infection in unvaccinated patients with cirrhosis is unknown.The objective of our study was to compare infection-induced and vaccine-induced immunity against COVID-19 among patients with cirrhosis. METHODS This was a retrospective cohort study among US Veterans with cirrhosis between November 27, 2020, and November 16, 2021, comparing a vaccine-induced immunity group, defined as participants without a documented SARS-CoV-2 infection but fully vaccinated with two doses of an mRNA vaccine, and infection-associated immunity group, defined as unvaccinated participants who had a positive SARS-CoV-2 polymerase chain reaction (PCR). Both groups were propensity score matched for observed characteristics, including location, and the date of the immunity acquiring event, to control for the community prevalence of COVID-19 variants. The outcome was a positive SARS-CoV-2 PCR more than 60 days after previous infection in the infection-induced, or after full vaccination in the vaccine-induced immunity group. RESULTS We compared 634 participants in the infection-induced immunity group with 27,131 participants in the vaccine-induced immunity group using inverse propensity of treatment weighting. Vaccine-induced immunity was associated with a reduced odds of developing SARS-CoV-2 infection (adjusted hazard ratio [aHR], 0.18; 95% confidence interval [CI], 0.16-0.20, p < 0.0001). On multivariable logistic regression, vaccine-induced immunity was associated with reduced odds of developing symptomatic (adjusted odds ratio [aOR], 0.36; 95% CI, 0.33-0.41, p < 0.0001), moderate/severe/critical (aOR, 0.27; 95% CI, 0.22-0.31, p < 0.0001), and severe or critical COVID-19 (aOR, 0.20; 95% CI, 0.16-0.26, p < 0.001), compared with infection-induced immunity. CONCLUSIONS In participants with cirrhosis, vaccine-induced immunity is associated with reduced risk of developing COVID-19, compared with infection-induced immunity.
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Affiliation(s)
- Binu V John
- Division of Gastroenterology and Hepatology , Miami VA Medical System , Miami , Florida , USA
- Division of Digestive Health and Liver Diseases , Department of Medicine , University of Miami Miller School of Medicine , Miami , Florida , USA
| | - Akash Doshi
- Division of Gastroenterology and Hepatology , Miami VA Medical System , Miami , Florida , USA
- University of Miami Miller School of Medicine , Miami , Florida , USA
| | - Raphaella D Ferreira
- Division of Gastroenterology and Hepatology , Miami VA Medical System , Miami , Florida , USA
| | - Tamar H Taddei
- Section of Digestive Diseases , Yale School of Medicine , New Haven , Connecticut , USA
- VA Connecticut Healthcare System , West Haven , Connecticut , USA
| | - David E Kaplan
- Division of Gastroenterology and Hepatology , University of Pennsylvania , Philadelphia , Pennsylvania , USA
- Division of Gastroenterology and Hepatology , Corporal Michael J. Crescenz VA Medical Center , Philadelphia , Pennsylvania , USA
| | - Seth A Spector
- Division of Surgery , Miami VA Medical System , Miami , Florida , USA
- Division of Surgery , University of Miami Miller School of Medicine , Miami , Florida , USA
| | - Yangyang Deng
- Department of Health Behavior and Policy , Virginia Commonwealth University , Richmond , Virginia , USA
| | - Dustin Bastaich
- Department of Health Behavior and Policy , Virginia Commonwealth University , Richmond , Virginia , USA
| | - Bassam Dahman
- Department of Health Behavior and Policy , Virginia Commonwealth University , Richmond , Virginia , USA
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15
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Edmonds MC, Kim SJ, Wells M, Dahman B, Sheppard VB. A Mixed Method Approach to Examine Surveillance Mammography Experiences in Black and White Breast Cancer Survivors. Clin Breast Cancer 2022; 22:801-811. [PMID: 36137937 DOI: 10.1016/j.clbc.2022.08.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2022] [Revised: 08/02/2022] [Accepted: 08/21/2022] [Indexed: 01/25/2023]
Abstract
PURPOSE The use of surveillance mammography following a breast cancer (BC) diagnosis is associated with early detection of disease relapse and increased overall survival; yet Black women compared to White women have the lowest surveillance mammography rates, with limited explanation. To further understand this racial disparity the present study examines the association of mammography beliefs, knowledge, and healthcare delivery factors on receipt of surveillance mammography among Black and White breast cancer survivors. METHODS This is a convergent parallel mixed method study design of an online survey and online focus groups among Black and White BC survivors (N = 266) recruited from community engagement. The online focus groups consisted of a series of theory-informed questions via social media platforms (eg Breastcancer.org, Quora, Reddit). An in-depth thematic analysis approach was used to extract themes from online focus group data. Bivariate (χ2) and multivariable logistic regression analyses were conducted using the survey data to examine associated factors with receipt of a surveillance mammography within 12 months (yes vs. no). RESULTS 76% (n = 177) of women were Black, 62% were <5 years since diagnosis, 98% had health insurance, with an age range from 23 to 79 (mean = 55) years. 72% of the sample received a surveillance mammogram relative to 27%. Women more frequently received a surveillance mammogram if they reported perceived mammography benefits (<.001), underwent lumpectomy (P< .001) and had health insurance (P = .04). Black women without communication about surveillance care with providers had a lower likelihood of receiving a surveillance mammogram (OR:0.09,95% CI: 0.01-0.45, P = .003). Thematic findings from online focus groups included motivators for receipt of surveillance mammograms: physician recommendation, regular physical exams, and knowledge of recommended guidelines. Barriers of non-receipt of surveillance mammograms included: transportation, medical cost/financial barriers, feeling ignored from providers, and medical mistrust. CONCLUSION Women may require more individualized information regarding their surveillance care to support routine guideline concordant follow-up. Patient-provider-communication is an integral part of Black survivors' surveillance care needs. Improving patient-provider communication for Black women's is necessary to address this group cancer care needs.
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Affiliation(s)
- Megan C Edmonds
- Division of General Internal Medicine, Icahn School of Medicine at Mount Sinai, New York, NY.
| | - Sunny Jung Kim
- Department of Health Behavior and Policy, School of Medicine, Virginia Commonwealth University, Richmond, VA
| | - Matthew Wells
- Department of Health Behavior and Policy, School of Medicine, Virginia Commonwealth University, Richmond, VA; VCU Massey Cancer Center, Richmond, VA
| | - Bassam Dahman
- Department of Health Behavior and Policy, School of Medicine, Virginia Commonwealth University, Richmond, VA
| | - Vanessa B Sheppard
- Department of Health Behavior and Policy, School of Medicine, Virginia Commonwealth University, Richmond, VA; VCU Massey Cancer Center, Richmond, VA
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Wheeler DC, Boyle J, Jeremy Barsell D, Maguire RL, Zhang J(J, Oliver JA, Jones S, Dahman B, Murphy SK, Hoyo C, Baggett CD, McClernon J, Fuemmeler BF. Tobacco Retail Outlets, Neighborhood Deprivation and the Risk of Prenatal Smoke Exposure. Nicotine Tob Res 2022; 24:2003-2010. [PMID: 35793204 PMCID: PMC9653076 DOI: 10.1093/ntr/ntac164] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2021] [Revised: 05/09/2022] [Accepted: 07/05/2022] [Indexed: 01/03/2023]
Abstract
INTRODUCTION Smoking and smoke exposure among pregnant women remain persistent public health issues. Recent estimates suggest that approximately one out of four nonsmokers have measurable levels of cotinine, a marker indicating regular exposure to secondhand smoke. Epidemiological research has attempted to pinpoint individual-level and neighborhood-level factors for smoking during pregnancy. However, most of these studies have relied upon self-reported measures of smoking. AIMS AND METHODS To more accurately assess smoke exposure resulting from both smoking and secondhand exposure in mothers during pregnancy, we used Bayesian regression models to estimate the association of cotinine levels with tobacco retail outlet (TRO) exposure and a neighborhood deprivation index (NDI) in six counties in North Carolina centered on Durham County. RESULTS Results showed a significant positive association between TRO exposure (β = 0.008, 95% credible interval (CI) = [0.003, 0.013]) and log cotinine after adjusting for individual covariates (eg, age, race/ethnicity, education, marital status). TRO exposure was not significant after including the NDI, which was significantly associated with log cotinine (β = 0.143, 95% CI = [0.030, 0.267]). However, in a low cotinine stratum (indicating secondhand smoke exposure), TRO exposure was significantly associated with log cotinine (β = 0.005, 95% CI = [0.001, 0.009]), while in a high cotinine stratum (indicating active smoking), the NDI was significantly associated with log cotinine (β = 0.176, 95% CI = [0.005, 0.372]). CONCLUSIONS In summary, our findings add to the evidence that contextual factors are important for active smoking during pregnancy. IMPLICATIONS In this study, we found several significant associations that suggest a more nuanced understanding of the potential influence of environmental- and individual-level factors for levels of prenatal smoke exposure. Results suggested a significant positive association between TRO exposure and cotinine levels, after adjusting for the individual factors such as race, education, and marital status. Individually, NDI was similarly positively associated with cotinine levels as well. However, when combining TRO exposure alongside NDI in the same model, TROs were no longer significantly associated with overall cotinine levels.
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Affiliation(s)
- David C Wheeler
- Department of Biostatistics, Virginia Commonwealth University, Richmond, VA 23298, USA
| | - Joseph Boyle
- Department of Biostatistics, Virginia Commonwealth University, Richmond, VA 23298, USA
| | - D Jeremy Barsell
- Department of Health Behavior and Policy, Virginia Commonwealth University, Richmond, VA 23298, USA
| | - Rachel L Maguire
- Department of Obstetrics and Gynecology, Duke University Medical Center, Durham, NC 27701, USA
- Department of Biological Sciences, Center for Human Health and the Environment, North Carolina State University, Raleigh, NC 27695, USA
| | - Junfeng (Jim) Zhang
- Environmental Science and Policy Division, Duke Global Health Institute and Nicholas School of the Environment, Durham, NC 27708, USA
| | - Jason A Oliver
- Department of Psychiatry and Behavioral Sciences, Duke University, Durham, NC 27701, USA
| | - Shaun Jones
- Department of Psychiatry and Behavioral Sciences, Duke University, Durham, NC 27701, USA
| | - Bassam Dahman
- Department of Health Behavior and Policy, Virginia Commonwealth University, Richmond, VA 23298, USA
| | - Susan K Murphy
- Department of Obstetrics and Gynecology, Duke University Medical Center, Durham, NC 27701, USA
| | - Cathrine Hoyo
- Department of Biological Sciences, Center for Human Health and the Environment, North Carolina State University, Raleigh, NC 27695, USA
| | - Chris D Baggett
- Department of Epidemiology, University of North Carolina, Chapel Hill, NC 27599, USA
| | - Joseph McClernon
- Department of Psychiatry and Behavioral Sciences, Duke University, Durham, NC 27701, USA
| | - Bernard F Fuemmeler
- Department of Health Behavior and Policy, Virginia Commonwealth University, Richmond, VA 23298, USA
- Massey Cancer Center, Virginia Commonwealth University, Richmond, VA 23298, USA
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17
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John BV, Ferreira RD, Doshi A, Kaplan DE, Taddei TH, Spector SA, Paulus E, Deng Y, Bastaich D, Dahman B. Third dose of COVID-19 mRNA vaccine appears to overcome vaccine hyporesponsiveness in patients with cirrhosis. J Hepatol 2022; 77:1349-1358. [PMID: 36181987 PMCID: PMC9519143 DOI: 10.1016/j.jhep.2022.07.036] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2022] [Revised: 07/05/2022] [Accepted: 07/06/2022] [Indexed: 02/06/2023]
Abstract
BACKGROUND & AIMS Cirrhosis is associated with immune dysregulation and hyporesponsiveness to several vaccines including those against COVID-19. Our aim was to compare outcomes between patients with cirrhosis who received 3 doses of either the Pfizer BNT162b2 mRNA or Moderna mRNA-1273 vaccines to a propensity-matched control group of patients at similar risk of infection who received 2 doses. METHODS This was a retrospective cohort study of patients with cirrhosis who received 2 or 3 doses of a COVID-19 mRNA vaccine at the Veterans Health Administration. Participants who received 3 doses of the vaccine (n = 13,041) were propensity score matched with 13,041 controls who received 2 doses, and studied between July 18, 2021 and February 11, 2022, when B.1.617.2 (delta) and B.1.1.529 (omicron) were the predominant variants. Outcomes were aggregated as all cases with COVID-19, symptomatic COVD-19, with at least moderate COVID-19, or severe or critical COVID-19. RESULTS Receipt of the third dose of a COVID-19 mRNA vaccine was associated with an 80.7% reduction in COVID-19 (95% CI 39.2-89.1, p <0.001), an 80.4% reduction in symptomatic COVID-19, an 80% reduction in moderate, severe or critical COVID-19, (95% CI 34.5-87.6%, p = 0.005), a 100% reduction in severe or critical COVID-19 (95% CI 99.2-100.0, p = 0.01), and a 100% reduction in COVID-19-related death (95% CI 99.8-100.0, p = 0.007). The magnitude of reduction in COVID-19 was greater with the third dose of BNT 162b2 than mRNA-1273 and among participants with compensated rather than decompensated cirrhosis. CONCLUSIONS Administration of a third dose of a COVID-19 mRNA vaccine was associated with a more significant reduction in COVID-19 in patients with cirrhosis than in the general population, suggesting that the third dose can overcome vaccine hyporesponsiveness in this population. LAY SUMMARY Cirrhosis is associated with decreased responsiveness to several vaccines, including those against COVID-19. In this study of 26,082 participants with cirrhosis during the delta and omicron surge, receipt of the third dose of the vaccine was associated with an 80% reduction in COVID-19, a 100% reduction in severe/critical COVID-19, and a 100% reduction in COVID-19-related death. These findings support the importance of a third dose of mRNA vaccine among patients with cirrhosis.
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Affiliation(s)
- Binu V John
- Division of Gastroenterology and Hepatology, Miami VA Medical System, Miami, FL, USA; Division of Digestive Health and Liver Disease, Department of Medicine, University of Miami Miller School of Medicine, Miami, FL, USA.
| | - Raphaella D Ferreira
- Division of Gastroenterology and Hepatology, Miami VA Medical System, Miami, FL, USA
| | - Akash Doshi
- University of Miami Miller School of Medicine, Miami, FL, USA
| | - David E Kaplan
- Division of Gastroenterology and Hepatology, University of Pennsylvania, Philadelphia, PA, USA; Division of Gastroenterology and Hepatology, Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA, USA
| | - Tamar H Taddei
- Section of Digestive Diseases, Yale School of Medicine, New Haven, CT, USA; VA Connecticut Healthcare System, West Haven, CT, USA
| | - Seth A Spector
- Department of Surgery, University of Miami Miller School of Medicine, Miami, FL, USA; Department of Surgery, Miami VA Medical System, Miami, FL, USA
| | - Elizabeth Paulus
- Department of Surgery, University of Miami Miller School of Medicine, Miami, FL, USA; Department of Surgery, Miami VA Medical System, Miami, FL, USA
| | - Yangyang Deng
- Department of Health Behavior and Policy, Virginia Commonwealth University, Richmond, VA, USA
| | - Dustin Bastaich
- Department of Health Behavior and Policy, Virginia Commonwealth University, Richmond, VA, USA
| | - Bassam Dahman
- Department of Health Behavior and Policy, Virginia Commonwealth University, Richmond, VA, USA
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18
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John BV, Sidney Barritt A, Moon A, Taddei TH, Kaplan DE, Dahman B, Doshi A, Deng Y, Mansour N, Ioannou G, Martin P, Chao HH. Effectiveness of COVID-19 Viral Vector Ad.26.COV2.S Vaccine and Comparison with mRNA Vaccines in Cirrhosis. Clin Gastroenterol Hepatol 2022; 20:2405-2408.e3. [PMID: 35716904 PMCID: PMC9212810 DOI: 10.1016/j.cgh.2022.05.038] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2022] [Revised: 05/24/2022] [Accepted: 05/24/2022] [Indexed: 12/26/2022]
Affiliation(s)
- Binu V John
- Division of Hepatology, Miami VA Medical System, Miami, Florida, and, Department of Medicine, University of Miami Miller School of Medicine, Miami, Florida.
| | - A Sidney Barritt
- Division of Gastroenterology and Hepatology, University of North Carolina, Chapel Hill, North Carolina
| | - Andrew Moon
- Division of Gastroenterology and Hepatology, University of North Carolina, Chapel Hill, North Carolina
| | - Tamar H Taddei
- Section of Digestive Diseases, Yale School of Medicine, New Haven, Connecticut, and, VA Connecticut Healthcare System, West Haven, Connecticut
| | - David E Kaplan
- Division of Gastroenterology and Hepatology, University of Pennsylvania, Philadelphia, Pennsylvania, and, Division of Gastroenterology and Hepatology, Corporal Michael J. Crescenz VA Medical Center, Philadelphia, Pennsylvania
| | - Bassam Dahman
- Department of Health Behavior and Policy, Virginia Commonwealth University, Richmond, Virginia
| | - Akash Doshi
- University of Miami Miller School of Medicine, Miami, Florida
| | - Yangyang Deng
- Department of Health Behavior and Policy, Virginia Commonwealth University, Richmond, Virginia
| | - Natalie Mansour
- Division of Hepatology, Miami VA Medical System, Miami, Florida
| | - George Ioannou
- Division of Gastroenterology and Hepatology, University of Washington, Seattle, Washington, and, Division of Gastroenterology and Hepatology, Puget Sound VA Medical Center, Seattle, Washington
| | - Paul Martin
- Department of Medicine, University of Miami Miller School of Medicine, Miami, Florida
| | - Hann-Hsiang Chao
- Department of Radiation Oncology, Central Virginia VA Medical System, Richmond, Virginia
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19
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John BV, Dahman B. Reply. Hepatology 2022; 77:E33-E34. [PMID: 36053772 PMCID: PMC9537866 DOI: 10.1002/hep.32749] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2022] [Accepted: 08/21/2022] [Indexed: 01/28/2023]
Affiliation(s)
- Binu V. John
- Division of Gastroenterology and HepatologyMiami Veterans Affairs Health SystemMiamiFloridaUSA,Division of Digestive Health and Liver DiseasesUniversity of Miami Miller School of MedicineMiamiFloridaUSA
| | - Bassam Dahman
- Department of Health Behavior and PolicyVirginia Commonwealth UniversityRichmondVirginiaUSA
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20
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John BV, Deng Y, Dahman B. Reply. Gastroenterology 2022; 163:531-532. [PMID: 35405121 PMCID: PMC8989689 DOI: 10.1053/j.gastro.2022.04.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2022] [Accepted: 04/05/2022] [Indexed: 12/02/2022]
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21
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Chukmaitov A, Dahman B, Garland SL, Dow A, Parsons PL, Harris KA, Sheppard VB. Addressing Social Risk Factors in the Inpatient Setting: Initial Findings from a Screening and Referral Pilot at an Urban Safety-Net Academic Medical Center in Virginia, USA. Prev Med Rep 2022; 29:101935. [PMID: 36161115 PMCID: PMC9501992 DOI: 10.1016/j.pmedr.2022.101935] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2022] [Revised: 07/20/2022] [Accepted: 07/26/2022] [Indexed: 11/18/2022] Open
Abstract
Social Determinants of Health (SDOH) impact health outcomes; thus, a pilot to screen for important SDOH domains (food, housing, and transportation) and address social needs in hospitalized patients was implemented in an urban safety-net academic medical center. This study describes the pilot implementation and examines patient characteristics associated with SDOH-related needs. An internal medicine unit was designated as a pilot site. Outreach workers approached eligible patients (n = 1,135) to complete the SDOH screening survey at time of admission with 54% (n = 615) completing the survey between May 2019 and July 2020. Data from patient screening survey and electronic health records were linked to allow for examination of associations between SDOH needs for food, housing, and transportation and various demographic and clinical characteristics of patients in multivariate logistic regression models. Of 615 screened patients, 45% screened positive for any need. Of 275 patients with needs, 33% reported needs in 2, and 34% – in 3 domains. Medicaid beneficiaries were more likely than patients with private health insurance to screen positive for 2 and 3 needs; Black patients were more likely than White patients to screen positive for 1 and 3 needs; Patients with no designated primary care physician status screened positive for 1 need; Patients with a history of substance use disorder screened positive for all 3 needs. SDOH screening assisted in addressing social risk factors of inpatients, informed their discharge plans and linkage to community resources. SDOH screening demonstrated significant correlations of positive screens with race/ethnicity, insurance type, and certain clinical characteristics.
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Affiliation(s)
- Askar Chukmaitov
- Virginia Commonwealth University (VCU) School of Medicine, Department of Health Behavior and Policy, 830 E. Main Str, Richmond, VA 23219, USA
- Corresponding author.
| | - Bassam Dahman
- Virginia Commonwealth University (VCU) School of Medicine, Department of Health Behavior and Policy, 830 E. Main Str, Richmond, VA 23219, USA
| | | | - Alan Dow
- VCU School of Medicine, Division of Hospital Medicine; VCU Health Sciences for Interprofessional Education & Collaborative Care; VCU Health Continuing Education; VCU Department of Health Administration, Richmond, USA
| | - Pamela L. Parsons
- VCU School of Nursing, Department of Family and Community Health Nursing; Richmond Memorial Health Foundation, Richmond, USA
| | - Kevin A. Harris
- VCU School of Medicine Dean's Office for Diversity, Equity and Inclusion, Richmond, USA
| | - Vanessa B. Sheppard
- Virginia Commonwealth University (VCU) School of Medicine, Department of Health Behavior and Policy, 830 E. Main Str, Richmond, VA 23219, USA
- VCU Massey Cancer Center, Richmond, USA
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22
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John BV, Deng Y, Schwartz KB, Taddei TH, Kaplan DE, Martin P, Chao H, Dahman B. Postvaccination COVID-19 infection is associated with reduced mortality in patients with cirrhosis. Hepatology 2022; 76:126-138. [PMID: 35023206 PMCID: PMC9015228 DOI: 10.1002/hep.32337] [Citation(s) in RCA: 45] [Impact Index Per Article: 22.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2021] [Revised: 12/12/2021] [Accepted: 01/08/2022] [Indexed: 02/03/2023]
Abstract
BACKGROUND AND AIMS Patients develop breakthrough COVID-19 infection despite vaccination. The aim of this study was to identify outcomes in patients with cirrhosis who developed postvaccination COVID-19. METHODS We performed a retrospective cohort study among US veterans with cirrhosis and postvaccination or unvaccinated COVID-19. Patients were considered fully vaccinated if COVID-19 was diagnosed 14 days after the second dose of either the Pfizer BNT162b2, the Moderna 1273-mRNA, or the single-dose Janssen Ad.26.COV2.S vaccines and partially vaccinated if COVID-19 was diagnosed 7 days after the first dose of any vaccine but prior to full vaccination. We investigated the association of postvaccination COVID-19 with mortality. RESULTS We identified 3242 unvaccinated and 254 postvaccination COVID-19 patients with cirrhosis (82 after full and 172 after partial vaccination). In a multivariable analysis of a 1:2 propensity-matched cohort including vaccinated (n = 254) and unvaccinated (n = 508) participants, postvaccination COVID-19 was associated with reduced risk of death (adjusted HR [aHR], 0.21; 95% CI, 0.11-0.42). The reduction was observed after both full (aHR, 0.22; 95% CI, 0.08-0.63) and partial (aHR, 0.19; 95% CI, 0.07-0.54) vaccination, following the 1273-mRNA (aHR, 0.12; 95% CI 0.04-0.37) and BNT162b2 (aHR, 0.27; 95% CI, 0.10-0.71) vaccines and among patients with compensated (aHR, 0.19; 95% CI, 0.08-0.45) and decompensated (aHR, 0.27; 95% CI, 0.08-0.90) cirrhosis. Findings were consistent in a sensitivity analysis restricted to participants who developed COVID-19 after vaccine availability. CONCLUSIONS Though patients with cirrhosis can develop breakthrough COVID-19 after full or partial vaccination, these infections are associated with reduced mortality.
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Affiliation(s)
- Binu V. John
- Division of HepatologyMiami VA Health SystemMiamiFloridaUSA
- Division of Digestive Health and Liver DiseasesUniversity of Miami Miller School of MedicineMiamiFloridaUSA
| | - Yangyang Deng
- Department of Health Behavior and PolicyVirginia Commonwealth UniversityRichmondVirginiaUSA
| | | | - Tamar H. Taddei
- Section of Digestive DiseasesYale School of MedicineNew HavenConnecticutUSA
- VA Connecticut Healthcare SystemWest HavenConnecticutUSA
| | - David E. Kaplan
- Division of Gastroenterology and HepatologyUniversity of PennsylvaniaPhiladelphiaPennsylvaniaUSA
- Division of Gastroenterology and HepatologyCorporal Michael J. Crescenz VA Medical CenterPhiladelphiaPennsylvaniaUSA
| | - Paul Martin
- Division of HepatologyMiami VA Health SystemMiamiFloridaUSA
- Division of Digestive Health and Liver DiseasesUniversity of Miami Miller School of MedicineMiamiFloridaUSA
| | - Hann‐Hsiang Chao
- Department of Radiation OncologyCentral Virginia VA Health Care SystemRichmondVirginiaUSA
| | - Bassam Dahman
- Department of Health Behavior and PolicyVirginia Commonwealth UniversityRichmondVirginiaUSA
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23
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Patel N, Dahman B, Bajaj JS. Development of New Mental and Physical Health Sequelae among US Veterans after COVID-19. J Clin Med 2022; 11:jcm11123390. [PMID: 35743461 PMCID: PMC9225186 DOI: 10.3390/jcm11123390] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2022] [Revised: 06/05/2022] [Accepted: 06/09/2022] [Indexed: 12/15/2022] Open
Abstract
Background:COVID-19 sequelae among veterans need evaluation. Design: Propensity-score-matched retrospective cohort study. Participants: A total 778,738 veterans, who were tested for COVID-19 at VA facilities between 20 February 2020−27 March 2021. Main Outcomes: Development of new physical and mental health conditions (incidence) during the follow-up period of 7 days to 3 months after the diagnosis of COVID-19. Results: Out of 778,738 veterans, 149,205 (19.2%) were inpatients and 629,533 (80.8%) were outpatients. 123,757 (15.9%) diagnosed with COVID-19. Mean age was 61 ± 15.4, mostly men (89%) who were White (68%) and non-Hispanic (88%). In hospitalized patients, COVID-19 is associated with significantly higher incidences of physical conditions (venous thromboembolism (5.8% vs. 2.9%, p < 0.001), pulmonary circulation disorder (5.1% vs. 2.9%, p < 0.001), chronic lung disease (8.4% vs. 4.3%, p < 0.001), acute kidney injury (16.4% vs. 9.3%, p < 0.001), chronic kidney disease (6.5% vs. 4.8%, p < 0.001), cardiac arrhythmia (15.2% vs. 10.9%, p < 0.001), complicated hypertension (12% vs. 8.5%, p < 0.001), coagulopathy (6.1% vs. 2.6%, p < 0.001), fluid/electrolyte disorders (24.4% vs. 12.6%, p < 0.001) and neurological disorders (7.1% vs. 3.8%, p < 0.001)) and mental health conditions (depressive episode (6.6% vs. 4.3%, p < 0.001), adjustment disorder (2.5% vs. 1.7%, p < 0.001), insomnia (4.9% vs. 3.2%, p < 0.001) and dementia (3.0% vs. 1.9%, p < 0.001)) compared to propensity-matched hospitalized COVID-19 negative patients. In outpatient settings, COVID-19 diagnosis is associated with smaller increase in the incidences of the physical sequelae. Conclusions: In this propensity-score-matched analysis of US veterans, COVID-19 survivors, especially those who were hospitalized, developed new physical and mental health sequelae at a significantly higher rate than those without COVID-19.
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Affiliation(s)
- Nilang Patel
- Department of Medicine, Virginia Commonwealth University, Richmond, VA 23298, USA;
- Division of Nephrology, Central Virginia VA Health Care System, 1201 Broad Rock Boulevard, Richmond, VA 23249, USA
- Correspondence: ; Tel.: +1-804-675-5596; Fax: +1-804-675-5159
| | - Bassam Dahman
- Department of Health Behavior and Policy, Virginia Commonwealth University, Richmond, VA 23298, USA;
- Department of Biostatistics, Virginia Commonwealth University, Richmond, VA 23298, USA
- Senior Health and Policy Analyst (WOC), Central Virginia VA Health Care System, Richmond, VA 23249, USA
| | - Jasmohan S. Bajaj
- Department of Medicine, Virginia Commonwealth University, Richmond, VA 23298, USA;
- Division of Gastroenterology and Hepatology, Central Virginia VA Health Care System, Richmond, VA 23249, USA
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24
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Brickhouse TH, Yu J, Kumar AM, Dahman B. The Impact of Preventive Dental Services on Subsequent Dental Treatment for Children in Medicaid. JDR Clin Trans Res 2022:23800844221096317. [PMID: 35499130 DOI: 10.1177/23800844221096317] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE The goal of this study was to use claims data linked with community-level measures to evaluate the impact of preventive services on the time to subsequent restorative, advanced restorative, and complex dental treatment among children enrolled in the Virginia Medicaid program. METHODS Four data sources were used (dental claims, eligibility files, American Community Survey, and Area Health Resource Files) for fiscal years 2011 to 2018. The outcomes of interest were time to first treatment services from birth. The treatment outcomes were basic restorative treatment, advanced restorative treatment, or complex treatment. The independent variable was a preventive service prior to a treatment service. Time-to-event curves were estimated and compared using a log-rank test. Propensity score-matched univariate and multivariate Cox proportional hazards frailty models with an inverse probability censoring weighting correction estimated hazard ratios (HRs) for treatment outcomes comparing use of preventive services while controlling for patient demographic, geospatial, and county-level socioeconomic status measures. RESULTS The analysis included 430,594 children (10,204,182 claims). A log-rank test showed significant differences (P < 0.001) between the times to treatment of those who had a preventive service and those who did not have a preventive service prior to a treatment service. Both Kaplan-Meier curves and the adjusted HR (1.88; 95% confidence interval [CI], 1.46-2.15) indicated that children without preventive services were more likely to have basic restorative treatment at an earlier age along with advanced restorative treatment (HR, 1.52; 95% CI, 1.28-1.80) and complex treatment (HR, 2.13; 95% CI, 1.68-2.61). CONCLUSIONS In a population of Medicaid-enrolled children, children who did not receive preventive services were significantly more likely to have treatment at an earlier age than those who did receive preventive services. KNOWLEDGE TRANSFER STATEMENT This study examines the impact of the utilization of preventive dental services since birth and the subsequent dental treatment for children enrolled in a dental Medicaid program. This study also examines the influence of preventive care on dental complexity of treatment for these children. Findings can inform federal and state policy planning of dental Medicaid programs as well as interventions to improve referral systems for the early use of preventive dental services and the establishment of a dental home.
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Affiliation(s)
- T H Brickhouse
- Department of Dental Public Health and Policy, School of Dentistry, Virginia Commonwealth University, Richmond, VA, USA.,Institute for Inclusion, Inquiry, and Innovation, Virginia Commonwealth University, Richmond, VA, USA
| | - J Yu
- Department of Biostatistics, School of Medicine, Virginia Commonwealth University, Richmond, VA, USA
| | - A M Kumar
- Department of Health Behavior and Policy, School of Medicine, Virginia Commonwealth University, Richmond, VA, USA
| | - B Dahman
- Department of Health Behavior and Policy, School of Medicine, Virginia Commonwealth University, Richmond, VA, USA
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Chao HH, Soni PD, Dahman B, Stilianoudakis SC, Ford H, Singh R, Freedland SJ, Moghanaki D, Vapiwala N, Chang MG. Outcomes following radical prostatectomy or external beam radiation for veterans with Gleason 9 and 10 prostate cancer. Cancer Med 2022; 11:2886-2895. [PMID: 35289111 PMCID: PMC9359878 DOI: 10.1002/cam4.4656] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2021] [Revised: 02/03/2022] [Accepted: 02/20/2022] [Indexed: 11/18/2022] Open
Abstract
Background The optimal upfront treatment modality for patients with nonmetastatic Gleason Score 9 and 10 prostate cancer (GS 9–10 PCa) is unknown. Methods We conducted a retrospective cohort study of patients in the Veterans Health Administration (VHA) with GS 9–10 PCa treated with radical prostatectomy (RP) or external beam radiation therapy with androgen deprivation therapy (EBRT+ADT) from 1/2000 to 12/2010. Outcomes included overall survival (OS), distant metastasis‐free survival (DMFS), and salvage/adjuvant therapy‐free survival (SAFS), as assessed by Kaplan–Meier analysis. Results We identified 1220 veterans with GS 9–10 PCa; 335 were treated with RP, and 885 were treated with EBRT+ADT. With a median follow‐up of 9.9 years, propensity score‐matched analyses demonstrated that RP had superior 10‐year OS (70.8% [RP] vs. 61.2% [EBRT+ADT], p < 0.001), 10‐year DMFS rates were similar between RP (76.7%) and EBRT+ADT (81.0%), and 10‐year SAFS rates were lower for RP vs EBRT + ADT (35.2% [RP] vs. 75.2% [EBRT+ADT], p < 0.001). The receipt of salvage ADT was higher with upfront RP (51.9% vs. 26.1%, p < 0.001), despite receipt of adjuvant/salvage EBRT in 41.8% of RP patients. Among patients treated with RP, there were no differences in outcomes by race. However, higher survival rates were noted among Black patients treated with EBRT+ADT compared with White patients. Conclusions This analysis demonstrated higher 10‐year OS rates among men treated with upfront RP versus EBRT+ADT, though missing confounders and similar DMFS rates suggest the long‐term cause‐specific OS rates may be similar. We also highlight real‐world outcomes of a diverse patient population in the VHA and improved outcomes for Black patients receiving EBRT+ADT.
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Affiliation(s)
- Hann-Hsiang Chao
- Radiation Oncology Service, Hunter Holmes McGuire VA Medical Center, Richmond, Virginia, USA.,Department of Radiation Oncology, Virginia Commonwealth University, Richmond, Virginia, USA
| | - Payal D Soni
- Radiation Oncology Service, Hunter Holmes McGuire VA Medical Center, Richmond, Virginia, USA
| | - Bassam Dahman
- Department of Health Behavior and Policy, Virginia Commonwealth University, Richmond, Virginia, USA.,Department of Biostatistics, Virginia Commonwealth University, Richmond, Virginia, USA
| | | | - Hampton Ford
- Radiation Oncology Service, Hunter Holmes McGuire VA Medical Center, Richmond, Virginia, USA
| | - Raj Singh
- Department of Radiation Oncology, Virginia Commonwealth University, Richmond, Virginia, USA
| | - Stephen J Freedland
- Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, California, USA.,Section of Urology, Durham, VA Medical Center, Durham, North Carolina, United States
| | - Drew Moghanaki
- Radiation Oncology Service, VA Greater Los Angeles Healthcare System, Los Angeles, California, USA.,Department of Radiation Oncology, University of California Los Angeles, Los Angeles, California, USA
| | - Neha Vapiwala
- Department of Radiation Oncology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Michael G Chang
- Radiation Oncology Service, Hunter Holmes McGuire VA Medical Center, Richmond, Virginia, USA.,Department of Radiation Oncology, Virginia Commonwealth University, Richmond, Virginia, USA
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26
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Wheeler DC, Boyle J, Barsell DJ, Maguire RL, Dahman B, Murphy SK, Hoyo C, Zhang J, Oliver JA, McClernon J, Fuemmeler BF. Neighborhood Deprivation is Associated with Increased Risk of Prenatal Smoke Exposure. Prev Sci 2022; 23:1078-1089. [PMID: 35179695 DOI: 10.1007/s11121-022-01355-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/07/2022] [Indexed: 02/01/2023]
Abstract
Despite years of advisories against the behavior, smoking among pregnant women remains a persistent public health issue in the USA. Recent estimates suggest that 9.4% of women smoke before pregnancy and 7.1% during pregnancy in the USA. Epidemiological research has attempted to pinpoint individual-level and neighborhood-level factors for smoking during pregnancy, including educational attainment, employment status, housing conditions, poverty, and racial demographics. However, most of these studies have relied upon self-reported measures of smoking, which are subject to reporting bias. To more accurately and objectively assess smoke exposure in mothers during pregnancy, we used Bayesian index models to estimate a neighborhood deprivation index (NDI) for block groups in Durham County, North Carolina, and its association with cotinine, a marker of smoke exposure, in pregnant mothers (n = 887 enrolled 2005-2011). Results showed a significant positive association between NDI and log cotinine (beta = 0.20, 95% credible interval = [0.11, 0.29]) after adjusting for individual covariates (e.g., race/ethnicity and education). The two most important variables in the NDI according to the estimated index weights were percent females without a high school degree and percent Black population. At the individual level, Hispanic and other race/ethnicity were associated with lowered cotinine compared with non-Hispanic Whites. Higher education levels were also associated with lowered cotinine. In summary, our findings provide stronger evidence that the socio-geographic variables of educational attainment and neighborhood racial composition are important factors for smoking and secondhand smoke exposure during pregnancy and can be used to target intervention efforts.
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Affiliation(s)
- David C Wheeler
- Department of Biostatistics, One Capitol Square, Virginia Commonwealth University, 7th Floor, 830 East Main St, Richmond, VA, 23298, USA.
| | - Joseph Boyle
- Department of Biostatistics, One Capitol Square, Virginia Commonwealth University, 7th Floor, 830 East Main St, Richmond, VA, 23298, USA
| | - D Jeremy Barsell
- Department of Health Behavior and Policy, Virginia Commonwealth University, Richmond, VA, 23298-0032, USA
| | - Rachel L Maguire
- Department of Obstetrics and Gynecology, Duke University Medical Center, Durham, NC, 27710, USA.,Department of Biological Sciences, Center for Human Health and the Environment, North Carolina State University, Raleigh, NC, 27695, USA
| | - Bassam Dahman
- Department of Health Behavior and Policy, Virginia Commonwealth University, Richmond, VA, 23298-0032, USA
| | - Susan K Murphy
- Department of Obstetrics and Gynecology, Duke University Medical Center, Durham, NC, 27710, USA
| | - Cathrine Hoyo
- Department of Biological Sciences, Center for Human Health and the Environment, North Carolina State University, Raleigh, NC, 27695, USA
| | - Jim Zhang
- Duke Global Health Institute, Durham, NC, 27708, USA
| | - Jason A Oliver
- Department of Psychiatry and Behavioral Sciences, Duke University, Durham, NC, 27701, USA.,TSET Health Promotion Research Center, Stephenson Cancer Center, Oklahoma City, OK, 73104, USA.,Department of Psychiatry and Behavioral Sciences, Oklahoma State University Center for Health Sciences, Tulsa, OK, 74136, USA
| | - Joseph McClernon
- Department of Psychiatry and Behavioral Sciences, Duke University, Durham, NC, 27701, USA
| | - Bernard F Fuemmeler
- Department of Health Behavior and Policy, Virginia Commonwealth University, Richmond, VA, 23298-0032, USA.,Massey Cancer Center, Virginia Commonwealth University, Richmond, VA, 23298, USA
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John B, Porter K, Dahman B, Parikh N, Silva AC, Yang JD, Joseph P, Strong LE, Limburg PJ. A prospective trial to evaluate the performance of the multitarget hepatocellular carcinoma blood test (mt-HBT) for screening at-risk patients: The Altus study. J Clin Oncol 2022. [DOI: 10.1200/jco.2022.40.4_suppl.tps486] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
TPS486 Background: Hepatocellular carcinoma (HCC) is a major cause of cancer-related death in the U.S. HCC surveillance is associated with improved early detection and receipt of curative treatment. However, current surveillance strategies suffer from low adherence and suboptimal sensitivity. The multi-target HCC blood test (mt-HBT) is a novel early detection assay that provides a qualitative result based on a multiparametric algorithm that incorporates information from methylation markers ( HOXA1, TSPYL5, and B3GALT6), AFP, and patient sex. Here, we describe the protocol for a prospective, multicenter clinical trial designed to investigate the performance of the mt-HBT in patients at risk for HCC. Methods: ALTernative to U/S (ALTUS) is a longitudinal, multicenter, prospective study with a targeted enrollment of 3,000 participants. The main inclusion and exclusion criteria are described in the table. Participants will receive HCC surveillance imaging (either U/S or CT/MRI) and blood collection for the mt-HBT. Those with positive U/S are anticipated to receive standard-of-care imaging follow-up with a multiphase CT or MRI, and those with a negative U/S will receive a study CT/MRI within 30 days of blood collection. Imaging interpretation is based on the CT/MRI LI-RADS (LR) v2018 categories. The primary endpoints are the overall sensitivity and specificity of the mt-HBT to detect HCC, defined as pathology-confirmed HCC or hepatocellular cholangiocarcinoma (cHCC-CCA), LR-4/5, or LR-TIV/M plus definite/probable HCC or cHCC-CCA. The secondary endpoints are mt-HBT early-stage sensitivity, and performance in a) participants with LR-5 or biopsy-confirmed HCC and b) participants confirmed non-HCC. Participants not diagnosed with a liver malignancy at visit one will continue to receive HCC surveillance, returning for a second visit ̃6 months from first blood collection. Blood will be collected after the second visit for the mt-HBT. Data on treatment will be collected for those diagnosed with HCC. Study participants and providers will be blinded to the mt-HBT results. Participants are currently enrolling across the U.S., with 60 targeted sites and an anticipated 12-month enrollment window. Clinical trial information: NCT05064553. [Table: see text]
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Affiliation(s)
| | | | | | | | | | | | | | - Laura E. Strong
- Independent science (formerly Exact Sciences Corporation), Madison, WI
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28
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John BV, Deng Y, Khakoo NS, Taddei TH, Kaplan DE, Dahman B. Coronavirus Disease 2019 Vaccination Is Associated With Reduced Severe Acute Respiratory Syndrome Coronavirus 2 Infection and Death in Liver Transplant Recipients. Gastroenterology 2022; 162:645-647.e2. [PMID: 34758352 PMCID: PMC8572555 DOI: 10.1053/j.gastro.2021.11.001] [Citation(s) in RCA: 23] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2021] [Revised: 10/27/2021] [Accepted: 11/01/2021] [Indexed: 12/13/2022]
Affiliation(s)
- Binu V. John
- Correspondence Address correspondence to: Binu V John, MD, MPH, University of Miami Miller School of Medicine, Miami VA Health System, 1201 NW 16th Street, D1004, Miami, Florida 33125
| | - Yangyang Deng
- Department of Health Behavior and Policy, Virginia Commonwealth University, Richmond, Virginia
| | - Nidah S Khakoo
- Department of Medicine, Jackson Memorial Hospital, Miami, Florida
| | - Tamar H Taddei
- Section of Digestive Diseases, Yale School of Medicine, New Haven, Connecticut; VA Connecticut Healthcare System, West Haven, Connecticut
| | - David E Kaplan
- Division of Gastroenterology and Hepatology, University of Pennsylvania, Philadelphia, Pennsylvania; Division of Gastroenterology and Hepatology, Corporal Michael J. Crescenz VA Medical Center, Philadelphia, Pennsylvania
| | - Bassam Dahman
- Department of Health Behavior and Policy, Virginia Commonwealth University, Richmond, Virginia
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29
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John BV, Dahman B, Deng Y, Khakoo NS, Taddei TH, Kaplan DE, Levy C. Rates of decompensation, hepatocellular carcinoma and mortality in AMA-negative primary biliary cholangitis cirrhosis. Liver Int 2022; 42:384-393. [PMID: 34614294 PMCID: PMC8810619 DOI: 10.1111/liv.15079] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2021] [Revised: 09/21/2021] [Accepted: 09/30/2021] [Indexed: 02/03/2023]
Abstract
BACKGROUND The natural history of patients with anti-mitochondrial antibody (AMA)-negative Primary Biliary Cholangitis (PBC) cirrhosis has not been well defined, with prior studies showing discordant results. Furthermore, most studies of AMA-negative PBC have limited numbers of patients with cirrhosis and liver-related outcomes. METHODS We investigated the association of AMA-negative PBC and the development of death, liver-related death, decompensation and hepatocellular carcinoma (HCC), in a large cohort of predominantly male patients with PBC cirrhosis assembled from the Veterans Health Administration. RESULTS In a cohort of 521 patients with PBC cirrhosis (65 AMA-negative) with a total follow-up of 2504.3 person-years (PY) from cirrhosis diagnosis, patients with AMA-negative PBC were younger and more likely to be black but had similar rates of UDCA response. AMA-negative PBC cirrhosis was associated with similar unadjusted rates of liver-related death (4.6 vs 5.9 per 100 PY, P = .44), overall death (7.7 vs 9.6 per 100 PY, P = .31), decompensation (7.3 vs 5.1 per 100 PY, P = .12) and HCC (0.6 vs 1.0 per 100 PY, P = .63) to AMA-positive PBC. After adjusting for confounders, AMA-negative PBC cirrhosis was associated with similar rates of liver-related death (sub-Hazard Ratio [sHR] 1.27, 95% CI 0.71-2.28, P = .42, death [sHR] 1.24, 95% CI 0.81-1.90, P = .32), decompensation (sHR 1.05, 95% CI 0.56-1.98, P = .87) and HCC (sHR 0.48, 95% CI 0.11-2.10, P = .33) to AMA-positive patients. CONCLUSION In a cohort of predominantly male patients, AMA-negative PBC cirrhosis was associated with similar rates of overall or liver-related death, HCC or decompensation compared with AMA-positive disease.
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Affiliation(s)
- Binu V John
- Division of Hepatology, Bruce W Carter VA Medical Center, Miami, Florida, USA
- Division of Digestive Health and Liver Diseases, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Bassam Dahman
- Department of Health Behavior and Policy, Virginia Commonwealth University, Richmond, Virginia, USA
| | - Yangyang Deng
- Department of Health Behavior and Policy, Virginia Commonwealth University, Richmond, Virginia, USA
| | - Nidah S Khakoo
- Department of Medicine, Jackson Memorial Hospital, Miami, Florida, USA
| | - Tamar H Taddei
- Section of Digestive Diseases, Yale School of Medicine, New Haven, Connecticut, USA
- VA Connecticut Healthcare System, West Haven, Connecticut, USA
| | - David E Kaplan
- Division of Gastroenterology and Hepatology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Division of Gastroenterology and Hepatology, Corporal Michael J. Crescenz VA Medical Center, Philadelphia, Pennsylvania, USA
| | - Cynthia Levy
- Division of Digestive Health and Liver Diseases, University of Miami Miller School of Medicine, Miami, Florida, USA
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30
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Edmonds MC, Dahman B, McGuire K, Sheppard VB. Influential factors in Black and White breast cancer survivors' beliefs about breast cancer. Psychooncology 2022; 31:271-281. [PMID: 34590395 PMCID: PMC8818015 DOI: 10.1002/pon.5807] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2021] [Revised: 08/14/2021] [Accepted: 08/16/2021] [Indexed: 02/03/2023]
Abstract
PURPOSE Breast cancer beliefs are widely studied to improve preventative screening behaviors in women without cancer; however, limited research has examined breast cancer beliefs among breast cancer survivors. To fill this gap in research we investigated racial differences and the predicting role of influential factors (e.g., stage) in survivors' beliefs about their breast cancer. METHODS This study is a secondary analysis of data from the Narrowing Gap in Adjuvant Therapy Study (2006-2011), where Black (N = 210) and White women (N = 149) were interviewed within 20 weeks following their breast cancer diagnosis and primary surgery in Washington DC and Detroit, MI. Outcomes of this analysis were perceived susceptibility to a breast cancer recurrence and perceived severity of breast cancer. Bivariate analyses were conducted to assess racial differences in sample characteristics, and on the study outcomes. Adjusted multiple regression models examined correlates between independent variables (e.g., sociodemographic/clinical) and women's breast cancer beliefs about susceptibility of a recurrence and disease severity. RESULTS Most of the sample were Black women (58%), had breast-conserving surgery (64%), and were privately insured (67%). Black women reported higher perceived disease severity beliefs than White women (p = 0.004). Other associated factors with greater perceived severity beliefs included lower education (p = 0.008), public health insurance (p = 0.021) and greater levels of medical mistrust (p = 0.016). In our adjusted multiple regression models' women with lower satisfaction regarding financial aspects of their healthcare were more likely to have higher perceived severity beliefs (p = 0.007); women with stage II cancer compared to stage I had greater susceptibility beliefs to a cancer recurrence (p = 0.001). CONCLUSION We found racial differences in women's perceived severity beliefs, and identified theory-based clinical and psychosocial correlates in survivor's breast cancer beliefs by race. Specifically, women diagnosed at stage (II) compared to stage (I) reported greater perceived susceptibility to a recurrence. Survivors diagnosed at stage (I) and (III) cancers may serve as important target groups to monitor their surveillance and follow-up behaviors. This study contributes salient predictors in survivors' beliefs about their BC and informs navigation strategies to improve cancer survivorship recommendations in the context of psycho-oncology and follow-up cancer care.
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Affiliation(s)
- Megan C Edmonds
- Division of General Internal Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Bassam Dahman
- Department of Health Behavior and Policy, School of Medicine, Virginia Commonwealth University, Richmond, VA, USA
| | - Kandace McGuire
- Office of Health Equity and Disparities Research, VCU Massey Cancer Center, Richmond, VA, USA
| | - Vanessa B Sheppard
- Department of Health Behavior and Policy, School of Medicine, Virginia Commonwealth University, Richmond, VA, USA
- Office of Health Equity and Disparities Research, VCU Massey Cancer Center, Richmond, VA, USA
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31
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John BV, Schwartz K, Scheinberg AR, Dahman B, Spector S, Deng Y, Goldberg D, Martin P, Taddei TH, Kaplan DE. Evaluation Within 30 Days of Referral for Liver Transplantation is Associated with Reduced Mortality: A Multicenter Analysis of Patients Referred Within the VA Health System. Transplantation 2022; 106:72-84. [PMID: 33587434 PMCID: PMC8239056 DOI: 10.1097/tp.0000000000003615] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
BACKGROUND Successful liver transplantation offers the possibility of improved survival among patients with decompensated cirrhosis. However, there is wide variability in access to care and promptness of the transplant evaluation process in the United States. METHODS We performed a multicenter retrospective study of 1118 patients who underwent evaluation for liver transplantation at the 6 Veterans Affairs' transplant centers from 2013 to 2018. Of these, 832 patients were evaluated within 30 d and 286 > 30 d after referral. We studied the differential effects of the time from referral to evaluation on pretransplant and posttransplant mortality and transplant list dropout and explored predictors of early transplant evaluation. RESULTS Patients in the early evaluation group had a shorter adjusted time from referral to listing by 29.5 d (95% confidence interval [CI] -50.4, -8.5, P < 0.006), and referral to transplantation by 115.1 d (95% CI -179.5, -50.7, P < 0.0001). On a multivariable Cox hazard model, evaluation within 30 d of referral was associated with a significantly lower pretransplant mortality (adjusted hazard ratio [aHR] 0.70, 95% CI 0.54-0.91, P < 0.01), but not associated with transplant list dropout (aHR 0.95, 95% CI 0.65-1.39, P = 0.79) or posttransplant death (aHR 1.88, 95% CI 0.72-4.9, P = 0.20). An early evaluation within 30 d was positively associated with a higher MELD at referral (aHR 1.03, 95% CI 1.01-1.06, P = 0.006) and negatively associated with distance from the transplant center (aHR 0.99, 95% CI 0.99-0.99, P = 0.045). CONCLUSIONS Evaluation of patients referred for liver transplantation within 30 d is associated with a reduction in pretransplant mortality.
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Affiliation(s)
- Binu V John
- Division of Hepatology, Miami VA Medical Center, Miami, FL
| | - Kaley Schwartz
- Division of Hepatology, Miami VA Medical Center, Miami, FL
| | - Andrew R Scheinberg
- Division of Hospital Medicine, Department of Medicine, University of Miami Miller School of Medicine, Miami, FL
| | - Bassam Dahman
- Department of Health Behavior and Policy, Virginia Commonwealth University, Richmond, VA
| | - Seth Spector
- Department of Surgery, University of Miami Miller School of Medicine MD
- Department of Surgery, Miami VA Medical Center, Miami, FL
| | - Yangyang Deng
- Department of Health Behavior and Policy, Virginia Commonwealth University, Richmond, VA
| | - David Goldberg
- Division of Digestive Health and Liver Diseases, University of Miami Miller School of Medicine, Miami, FL
| | - Paul Martin
- Division of Digestive Health and Liver Diseases, University of Miami Miller School of Medicine, Miami, FL
| | - Tamar H. Taddei
- Section of Digestive Diseases, Yale School of Medicine, New Haven, CT
- Department of Gastroenterology, VA Connecticut Healthcare System, West Haven CT
| | - David E. Kaplan
- Department of Gastroenterology, Hospital at the University of Pennsylvania, Philadelphia, PA
- Department of Gastroenterology, Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA
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32
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John BV, Deng Y, Martin P, Levy C, Taddei TH, Kaplan DE, Dahman B. REPLY. Hepatology 2021; 74:2322-2323. [PMID: 34021933 PMCID: PMC8463433 DOI: 10.1002/hep.31917] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/08/2022]
Affiliation(s)
- Binu V. John
- Division of Hepatology, Bruce W Carter VA Medical Center,
Miami, FL,Division of Digestive Health and Liver Diseases,
University of Miami Miller School of Medicine, Miami, FL
| | - Yangyang Deng
- Department of Health Behavior and Policy, Virginia
Commonwealth University, Richmond, VA
| | - Paul Martin
- Division of Digestive Health and Liver Diseases,
University of Miami Miller School of Medicine, Miami, FL
| | - Cynthia Levy
- Division of Digestive Health and Liver Diseases,
University of Miami Miller School of Medicine, Miami, FL
| | - Tamar H. Taddei
- Section of Digestive Diseases, Yale School of Medicine,
New Haven, CT,VA Connecticut Healthcare System, West Haven, CT
| | - David E. Kaplan
- Division of Gastroenterology and Hepatology, University of
Pennsylvania, Philadelphia, PA,Division of Gastroenterology and Hepatology, Corporal
Michael J. Crescenz VA Medical Center, Philadelphia, PA
| | - Bassam Dahman
- Department of Health Behavior and Policy, Virginia
Commonwealth University, Richmond, VA
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33
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John BV, Deng Y, Scheinberg A, Mahmud N, Taddei TH, Kaplan D, Labrada M, Baracco G, Dahman B. Association of BNT162b2 mRNA and mRNA-1273 Vaccines With COVID-19 Infection and Hospitalization Among Patients With Cirrhosis. JAMA Intern Med 2021; 181:1306-1314. [PMID: 34254978 PMCID: PMC8278308 DOI: 10.1001/jamainternmed.2021.4325] [Citation(s) in RCA: 34] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
IMPORTANCE Two mRNA-based vaccines against coronavirus disease 2019 (COVID-19) were found to be highly efficacious in phase 3 clinical trials in the US. However, patients with chronic illnesses, including cirrhosis, were excluded from clinical trials. Patients with cirrhosis have immune dysregulation that is associated with vaccine hyporesponsiveness. OBJECTIVE To study the association of receipt of the Pfizer BNT162b2 mRNA or the Moderna mRNA-1273 vaccines in patients with cirrhosis compared with a propensity-matched control group of patients at similar risk of infection and severe disease from COVID-19. DESIGN, SETTING, AND PARTICIPANTS We performed a retrospective cohort study of patients with cirrhosis who received at least 1 dose of a COVID-19 mRNA vaccine at the Veterans Health Administration. Patients who received at least 1 dose of the vaccine (n = 20 037) were propensity matched with 20 037 controls to assess the associations of vaccination with new COVID-19 infection and COVID-19 hospitalization and death. EXPOSURES Receipt of at least 1 dose of the BNT162b2 mRNA or the mRNA-1273 vaccines between December 18, 2020, and March 17, 2021. MAIN OUTCOMES AND MEASURES COVID-19 infection as documented by a positive result for COVID-19 by polymerase chain reaction, hospitalization, and death due to COVID-19 infection. RESULTS The median (interquartile range) age of the vaccinated individuals in the study cohort was 69.1 (8.4) years and 19 465 (97.2%) of the participants in each of the vaccinated and unvaccinated groups were male, consistent with a US veteran population. The mRNA-1273 vaccine was administered in 10 236 (51%) and the BNT162b2 mRNA in 9801 (49%) patients. Approximately 99.7% of patients who received the first dose of either vaccine with a follow-up of 42 days or more received a second dose. The number of COVID-19 infections in the vaccine recipients was similar to the control group in days 0 to 7, 7 to 14, 14 to 21, and 21 to 28 after the first dose. After 28 days, receipt of 1 dose of an mRNA vaccine was associated with a 64.8% reduction in COVID-19 infections and 100% protection against hospitalization or death due to COVID-19 infection. The association of reduced COVID-19 infections after the first dose was lower among patients with decompensated (50.3%) compared with compensated cirrhosis (66.8%). Receipt of a second dose was associated with a 78.6% reduction in COVID-19 infections and 100% reduction in COVID-19-related hospitalization or death after 7 days. CONCLUSIONS AND RELEVANCE This cohort study of US veterans found that mRNA vaccine administration was associated with a delayed but modest reduction in COVID-19 infection but an excellent reduction in COVID-19-related hospitalization or death in patients with cirrhosis.
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Affiliation(s)
- Binu V John
- Division of Hepatology, Bruce W Carter VA Medical Center, Miami, Florida.,Department of Medicine, University of Miami Miller School of Medicine, Miami, Florida
| | - Yangyang Deng
- Department of Health Behavior and Policy, Virginia Commonwealth University, Richmond
| | - Andrew Scheinberg
- Department of Medicine, University of Miami Miller School of Medicine, Miami, Florida
| | - Nadim Mahmud
- Division of Gastroenterology and Hepatology, University of Pennsylvania, Philadelphia.,Division of Gastroenterology and Hepatology, Corporal Michael J. Crescenz VA Medical Center, Philadelphia, Pennsylvania
| | - Tamar H Taddei
- Section of Digestive Diseases, Yale School of Medicine, New Haven, Connecticut.,VA Connecticut Healthcare System, West Haven, Connecticut
| | - David Kaplan
- Division of Gastroenterology and Hepatology, University of Pennsylvania, Philadelphia.,Division of Gastroenterology and Hepatology, Corporal Michael J. Crescenz VA Medical Center, Philadelphia, Pennsylvania
| | - Mabel Labrada
- Department of Medicine, University of Miami Miller School of Medicine, Miami, Florida.,Department of Medicine, Bruce W. Carter VA Medical Center, Miami, Florida
| | - Gio Baracco
- Department of Medicine, University of Miami Miller School of Medicine, Miami, Florida.,Department of Infectious Disease Epidemiology, Bruce W. Carter VA Medical Center, Miami, Florida
| | - Bassam Dahman
- Department of Health Behavior and Policy, Virginia Commonwealth University, Richmond
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34
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John BV, Dahman B, Taddei TH, Levy C, Kaplan DE. REPLY. Hepatology 2021; 74:2308. [PMID: 33942361 PMCID: PMC8463416 DOI: 10.1002/hep.31876] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/08/2022]
Affiliation(s)
- Binu V. John
- Division of Hepatology, Bruce W Carter VA Medical Center,
Miami, FL,Division of Digestive Health and Liver Diseases,
University of Miami Miller School of Medicine, Miami, FL
| | - Bassam Dahman
- Department of Health Behavior and Policy, Virginia
Commonwealth University, Richmond, VA
| | - Tamar H. Taddei
- Section of Digestive Diseases, Yale School of Medicine,
New Haven, CT,VA Connecticut Healthcare System, West Haven, CT
| | - Cynthia Levy
- Division of Digestive Health and Liver Diseases,
University of Miami Miller School of Medicine, Miami, FL
| | - David E. Kaplan
- Division of Gastroenterology and Hepatology, University of
Pennsylvania, Philadelphia, PA,Division of Gastroenterology and Hepatology, Corporal
Michael J. Crescenz VA Medical Center, Philadelphia, PA
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John BV, Khakoo NS, Schwartz KB, Aitchenson G, Levy C, Dahman B, Deng Y, Goldberg DS, Martin P, Kaplan DE, Taddei TH. Ursodeoxycholic Acid Response Is Associated With Reduced Mortality in Primary Biliary Cholangitis With Compensated Cirrhosis. Am J Gastroenterol 2021; 116:1913-1923. [PMID: 33989225 PMCID: PMC8410631 DOI: 10.14309/ajg.0000000000001280] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2020] [Accepted: 03/12/2021] [Indexed: 12/11/2022]
Abstract
INTRODUCTION Patients with cirrhosis and men have been under-represented in most studies examining the clinical benefit of response to ursodeoxycholic acid (UDCA) in primary biliary cholangitis (PBC). The aim of this study was to study the association of UDCA response and liver-related death or transplantation, hepatic decompensation, and hepatocellular carcinoma (HCC) in patients with PBC cirrhosis. METHODS We conducted a retrospective cohort study of veterans, predominantly men, with PBC and compensated cirrhosis to assess the association of UDCA response with the development of all-cause and liver-related mortality or transplantation, hepatic decompensation, and HCC using competing risk time-updating Cox proportional hazards models. RESULTS We identified 501 subjects with PBC and compensated cirrhosis, including 287 UDCA responders (1,692.8 patient-years [PY] of follow-up) and 214 partial responders (838.9 PY of follow-up). The unadjusted rates of hepatic decompensation (3.8 vs 7.9 per 100 PY, P < 0.0001) and liver-related death or transplantation (3.7 vs 6.2 per 100 PY, P < 0.0001) were lower in UDCA responders compared with partial responders. UDCA response was associated with a lower risk of hepatic decompensation (subhazard ratio [sHR] 0.54, 95% confidence interval [CI] 0.31-0.95, P = 0.03), death from any cause or transplantation (adjusted hazard ratio 0.49, 95% CI 0.33-0.72, P = 0.0002), and liver-related death or transplantation (sHR 0.40, 95% CI 0.24-0.67, P = 0.0004), but not HCC (sHR 0.39, 95% CI 0.60-2.55, P = 0.32). In a sensitivity analysis, the presence of portal hypertension was associated with the highest UDCA-associated effect. DISCUSSION UDCA response is associated with a reduction in decompensation, all-cause, and liver-related death or transplantation in a cohort of predominantly male patients with cirrhosis, with the highest benefit in patients with portal hypertension.
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Affiliation(s)
- Binu V John
- Division of Hepatology, Bruce W Carter VA Medical Center, Miami, FL
| | | | - Kaley B Schwartz
- Division of Hepatology, Bruce W Carter VA Medical Center, Miami, FL
| | | | - Cynthia Levy
- Division of Digestive Health and Liver Diseases, University of Miami Miller School of Medicine, Miami, FL
| | - Bassam Dahman
- Department of Health Behavior and Policy, Virginia Commonwealth University, Richmond, VA
| | - Yangyang Deng
- Department of Health Behavior and Policy, Virginia Commonwealth University, Richmond, VA
| | - David S. Goldberg
- Division of Digestive Health and Liver Diseases, University of Miami Miller School of Medicine, Miami, FL
| | - Paul Martin
- Division of Digestive Health and Liver Diseases, University of Miami Miller School of Medicine, Miami, FL
| | - David E. Kaplan
- Division of Gastroenterology and Hepatology, University of Pennsylvania, Philadelphia, PA
- Division of Gastroenterology and Hepatology, Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA
| | - Tamar H. Taddei
- Section of Digestive Diseases, Yale School of Medicine, New Haven, CT
- Division of Gastroenterology and Hepatology, VA Connecticut Healthcare System, West Haven, CT
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Sabik LM, Eom KY, Dahman B, Li J, van Londen GJ, Bradley CJ. Breast Cancer Treatment Following Health Reform: Evidence From Massachusetts. Med Care Res Rev 2021; 79:371-381. [PMID: 34467806 DOI: 10.1177/10775587211042532] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
There are well-documented differences in breast cancer treatment by insurance status. Insurance expansions provide a context to assess the relationship between insurance and patterns of breast cancer care. We examine the association of Massachusetts health reform with use of breast conserving surgery, reconstruction, and adjuvant radiation using data from the Massachusetts Cancer Registry and Surveillance Epidemiology and End Results registries for 2001-2013 and a difference-in-differences approach. We observe statistically significant increases in breast conserving surgery among nonelderly women in Massachusetts relative to trends in states and age groups not affected by health reform. We also observe relative increases in reconstruction and adjuvant radiation, though trends in these outcomes were not the same across states prior to reform, limiting our ability to draw conclusions about the relationship between reform and these outcomes. Our results suggest that health reform was associated with some improvements in breast cancer treatment.
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Affiliation(s)
| | | | | | - Jie Li
- University of Pittsburgh, Pittsburgh, PA, USA
| | | | - Cathy J Bradley
- University of Colorado Comprehensive Cancer Center, Aurora, CO, USA
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John BV, Aitcheson G, Schwartz KB, Khakoo NS, Dahman B, Deng Y, Goldberg D, Martin P, Taddei TH, Levy C, Kaplan DE. Male Sex Is Associated With Higher Rates of Liver-Related Mortality in Primary Biliary Cholangitis and Cirrhosis. Hepatology 2021; 74:879-891. [PMID: 33636012 DOI: 10.1002/hep.31776] [Citation(s) in RCA: 33] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2020] [Revised: 01/10/2021] [Accepted: 02/01/2021] [Indexed: 12/18/2022]
Abstract
BACKGROUND AND AIMS The impact of sex on the postcirrhosis progression of primary biliary cholangitis (PBC) has not been well defined. Prior studies have suggested that men have worse outcomes but present at more advanced stages of fibrosis than women. This observation, however, has been limited by small numbers of men and even fewer patients with cirrhosis. APPROACH AND RESULTS We investigated the association of sex with the development of all-cause and liver-related mortality or transplantation, decompensation, and hepatocellular carcinoma (HCC), using competing-risk time-updating Cox proportional hazards models in a large cohort of predominantly male patients with PBC cirrhosis assembled from the Veterans Health Administration. In a cohort of 532 participants (418 male) with PBC-related cirrhosis with a total follow-up of 3,231.6 person-years (PY) from diagnosis of compensated cirrhosis, male participants had a higher unadjusted rates of death or transplantation (8.5 vs. 3.8 per 100 PY; P < 0.0001), liver-related death or transplantation (5.5 vs. 2.7 per 100 PY; P < 0.0001), decompensation (5.5 vs. 4.0 per 100 PY; P = 0.002), and HCC (0.9 vs. 0.3 per 100 PY; P < 0.0001). After adjusting for confounders, male sex was associated with a higher risk of death or transplantation (adjusted hazard ratio, 1.80; 95% CI, 1.01-3.19; P = 0.046), and liver-related death or transplantation (subhazard ratio, 2.17; 95% CI, 1.15-4.08; P = 0.02). A sensitivity analysis that defined ursodeoxycholic acid response as normalization of alkaline phosphatase and total bilirubin revealed similar findings. CONCLUSIONS In patients with PBC and well-compensated cirrhosis, male sex is associated with a higher risk of both death and liver-related death or transplantation.
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Affiliation(s)
- Binu V John
- Division of HepatologyBruce W Carter VA Medical CenterMiamiFLUSA
| | | | - Kaley B Schwartz
- Division of HepatologyBruce W Carter VA Medical CenterMiamiFLUSA
| | - Nidah S Khakoo
- Department of MedicineJackson Memorial HospitalMiamiFLUSA
| | - Bassam Dahman
- Department of Health Behavior and PolicyVirginia Commonwealth UniversityRichmondVAUSA
| | - Yangyang Deng
- Department of Health Behavior and PolicyVirginia Commonwealth UniversityRichmondVAUSA
| | - David Goldberg
- Division of Digestive Health and Liver DiseasesUniversity of Miami Miller School of MedicineMiamiFLUSA
| | - Paul Martin
- Division of Digestive Health and Liver DiseasesUniversity of Miami Miller School of MedicineMiamiFLUSA
| | - Tamar H Taddei
- Section of Digestive DiseasesYale School of MedicineNew HavenCTUSA.,Division of Gastroenterology and HepatologyVA Connecticut Healthcare SystemWest HavenCTUSA
| | - Cynthia Levy
- Division of Digestive Health and Liver DiseasesUniversity of Miami Miller School of MedicineMiamiFLUSA
| | - David E Kaplan
- Division of Gastroenterology and HepatologyUniversity of PennsylvaniaPhiladelphiaPAUSA.,Division of Gastroenterology and HepatologyCorporal Michael J. Crescenz VA Medical CenterPhiladelphiaPAUSA
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John BV, Schwartz K, Levy C, Dahman B, Deng Y, Martin P, Taddei TH, Kaplan DE. Impact of Obeticholic acid Exposure on Decompensation and Mortality in Primary Biliary Cholangitis and Cirrhosis. Hepatol Commun 2021; 5:1426-1436. [PMID: 34430786 PMCID: PMC8369937 DOI: 10.1002/hep4.1720] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2020] [Revised: 01/30/2021] [Accepted: 02/26/2021] [Indexed: 02/04/2023] Open
Abstract
Obeticholic acid (OCA) is approved for the treatment of patients with primary biliary cholangitis (PBC) who are partial responders or intolerant to ursodeoxycholic acid. Reports of serious liver injury have raised concerns about its safety in cirrhosis. We investigated the effects of treatment with OCA on hepatic decompensation and liver-related mortality or transplantation in a cohort with compensated PBC cirrhosis. This was a retrospective cohort study using national data of US veterans with PBC and cirrhosis. We performed a propensity score model using variables associated with OCA prescription to control for baseline risk of decompensation. New OCA users were matched to nonusers. We identified 509 subjects with compensated PBC cirrhosis. We developed a propensity score model using variables associated with OCA prescription; 21 OCA users were matched with 84 nonusers. Over 569 and 3,847 person-months, respectively, of follow-up, 5 (23.8%) OCA users and 22 (26.2%) OCA nonusers decompensated. The C-statistic of the propensity score model was 0.87. On multivariable analysis, after adjusting for potential confounders, OCA use was associated with an increased risk of hepatic decompensation (adjusted hazard ratio, 3.9; 95% confidence interval, 1.33-11.57; P = 0.01). There was no association between OCA use and liver-related mortality or transplantation (adjusted hazard ratio, 1.35; 95% confidence interval, 0.35-5.21; P = 0.66). Conclusion: OCA use was associated with an increase in hepatic decompensation but not liver-related mortality or transplantation in patients with compensated PBC cirrhosis. Additional studies are recommended to prospectively investigate these findings.
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Affiliation(s)
- Binu V John
- Division of HepatologyBruce W Carter VA Medical CenterMiamiFLUSA.,Division of Digestive Health and Liver DiseasesUniversity of Miami Miller School of MedicineMiamiFLUSA
| | - Kaley Schwartz
- Division of HepatologyBruce W Carter VA Medical CenterMiamiFLUSA
| | - Cynthia Levy
- Division of Digestive Health and Liver DiseasesUniversity of Miami Miller School of MedicineMiamiFLUSA
| | - Bassam Dahman
- Department of Health Behavior and PolicyVirginia Commonwealth UniversityRichmondVAUSA
| | - Yangyang Deng
- Department of Health Behavior and PolicyVirginia Commonwealth UniversityRichmondVAUSA
| | - Paul Martin
- Division of Digestive Health and Liver DiseasesUniversity of Miami Miller School of MedicineMiamiFLUSA
| | - Tamar H Taddei
- Section of Digestive DiseasesYale School of MedicineNew HavenCTUSA.,Division of Gastroenterology and HepatologyVA Connecticut Healthcare SystemWest HavenCTUSA
| | - David E Kaplan
- Division of Gastroenterology and HepatologyUniversity of PennsylvaniaPhiladelphiaPAUSA.,Division of Gastroenterology and HepatologyCorporal Michael J. Crescenz VA Medical CenterPhiladelphiaPAUSA
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Bono RS, Dahman B, Sabik LM, Yerkes LE, Deng Y, Belgrave FZ, Nixon DE, Rhodes AG, Kimmel AD. Human Immunodeficiency Virus-Experienced Clinician Workforce Capacity: Urban-Rural Disparities in the Southern United States. Clin Infect Dis 2021; 72:1615-1622. [PMID: 32211757 DOI: 10.1093/cid/ciaa300] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2019] [Accepted: 03/23/2020] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Human immunodeficiency virus (HIV)-experienced clinicians are critical for positive outcomes along the HIV care continuum. However, access to HIV-experienced clinicians may be limited, particularly in nonmetropolitan areas, where HIV is increasing. We examined HIV clinician workforce capacity, focusing on HIV experience and urban-rural differences, in the Southern United States. METHODS We used Medicaid claims and clinician characteristics (Medicaid Analytic eXtract [MAX] and MAX Provider Characteristics, 2009-2011), county-level rurality (National Center for Health Statistics, 2013), and diagnosed HIV cases (AIDSVu, 2014) to assess HIV clinician capacity in 14 states. We assumed that clinicians accepting Medicaid approximated the region's HIV workforce, since three-quarters of clinicians accept Medicaid insurance. HIV-experienced clinicians were defined as those providing care to ≥ 10 Medicaid enrollees over 3 years. We assessed HIV workforce capacity with county-level clinician-to-population ratios, using Wilcoxon-Mann-Whitney tests to compare urban-rural differences. RESULTS We identified 5012 clinicians providing routine HIV management, of whom 28% were HIV-experienced. HIV-experienced clinicians were more likely to specialize in infectious diseases (48% vs 6%, P < .001) and practice in urban areas (96% vs 83%, P < .001) compared to non-HIV-experienced clinicians. The median clinician-to-population ratio for all HIV clinicians was 13.3 (interquartile range, 38.0), with no significant urban-rural differences. When considering HIV experience, 81% of counties had no HIV-experienced clinicians, and rural counties generally had fewer HIV-experienced clinicians per 1000 diagnosed HIV cases (P < .001). CONCLUSIONS Significant urban-rural disparities exist in HIV-experienced workforce capacity for communities in the Southern United States. Policies to improve equity in access to HIV-experienced clinical care for both urban and rural communities are urgently needed.
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Affiliation(s)
- Rose S Bono
- Department of Health Behavior and Policy, Virginia Commonwealth University, Richmond, Virginia, USA
| | - Bassam Dahman
- Department of Health Behavior and Policy, Virginia Commonwealth University, Richmond, Virginia, USA
| | - Lindsay M Sabik
- Department of Health Policy and Management, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Lauren E Yerkes
- Division of Population Health Data, Virginia Department of Health, Richmond, Virginia, USA.,Division of Disease Prevention, Virginia Department of Health, Richmond, Virginia, USA
| | - Yangyang Deng
- Department of Health Behavior and Policy, Virginia Commonwealth University, Richmond, Virginia, USA
| | - Faye Z Belgrave
- Department of Psychology, Virginia Commonwealth University, Richmond, Virginia, USA
| | - Daniel E Nixon
- Department of Internal Medicine, Division of Infectious Diseases, Virginia Commonwealth University, Richmond, Virginia, USA
| | - Anne G Rhodes
- Division of Disease Prevention, Virginia Department of Health, Richmond, Virginia, USA
| | - April D Kimmel
- Department of Health Behavior and Policy, Virginia Commonwealth University, Richmond, Virginia, USA
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Eom KY, van Londen GJ, Li J, Dahman B, Bradley C, Sabik LM. Changes in initiation of adjuvant endocrine therapy for breast cancer after state health reform. BMC Cancer 2021; 21:487. [PMID: 33933027 PMCID: PMC8088064 DOI: 10.1186/s12885-021-08149-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2021] [Accepted: 03/30/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Socioeconomic differences in receipt of adjuvant treatment contribute to persistent disparities in breast cancer (BCA) outcomes, including survival. Adjuvant endocrine therapy (AET) substantially reduces recurrence risk and is recommended by clinical guidelines for nearly all women with hormone receptor-positive non-metastatic BCA. However, AET use among uninsured or underinsured populations has been understudied. The health reform implemented by the US state of Massachusetts in 2006 expanded health insurance coverage and increased the scope of benefits for many with coverage. This study examines changes in the initiation of AET among BCA patients in Massachusetts after the health reform. METHODS We used Massachusetts Cancer Registry data from 2004 to 2013 for a sample of estrogen receptor (ER)-positive BCA surgical patients aged 20-64 years. We estimated multivariable regression models to assess differential changes in the likelihood initiating AET after Massachusetts health reform by area-level income, comparing women from lower- and higher-income ZIP codes in Massachusetts. RESULTS There was a 5-percentage point (p-value< 0.001) relative increase in the likelihood of initiating AET among BCA patients aged 20-64 years in low-income areas, compared to higher-income areas, after the reform. The increase was more pronounced among younger patients aged 20-49 years (7.1-percentage point increase). CONCLUSIONS The expansion of health insurance in Massachusetts was associated with a significant relative increase in the likelihood of AET initiation among women in low-income areas compared with those in high-income areas. Our results suggest that expansions of health insurance coverage and improved access to care can increase the number of eligible patients initiating AET and may ameliorate socioeconomic disparities in BCA outcomes.
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Affiliation(s)
- Kirsten Y Eom
- Department of Health Policy and Management, University of Pittsburgh, 130 De Soto St, A663, Pittsburgh, PA, 15261, USA.
| | - G J van Londen
- Divisions of Hematology-Oncology and Geriatric Medicine, Department of Medicine, University of Pittsburgh, Pittsburgh, USA
| | - Jie Li
- Department of Health Policy and Management, University of Pittsburgh, 130 De Soto St, A663, Pittsburgh, PA, 15261, USA
| | - Bassam Dahman
- Department of Health Behavior and Policy, Virginia Commonwealth University, Richmond, USA
| | - Cathy Bradley
- University of Colorado Comprehensive Cancer Center, Aurora, USA
| | - Lindsay M Sabik
- Department of Health Policy and Management, University of Pittsburgh, 130 De Soto St, A663, Pittsburgh, PA, 15261, USA
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Sheppard VB, Sutton AL, Hurtado-de-Mendoza A, He J, Dahman B, Edmonds MC, Hackney MH, Tadesse MG. Race and Patient-reported Symptoms in Adherence to Adjuvant Endocrine Therapy: A Report from the Women's Hormonal Initiation and Persistence Study. Cancer Epidemiol Biomarkers Prev 2021; 30:699-709. [PMID: 33514603 PMCID: PMC8330157 DOI: 10.1158/1055-9965.epi-20-0604] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2020] [Revised: 07/14/2020] [Accepted: 01/26/2021] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Adjuvant endocrine therapy (AET) improves outcomes in women with hormone receptor-positive (HR+) breast cancer. Suboptimal AET adherence is common, but data are lacking about symptoms and adherence in racial/ethnic minorities. We evaluated adherence by race and the relationship between symptoms and adherence. METHODS The Women's Hormonal Initiation and Persistence study included women diagnosed with nonrecurrent HR+ breast cancer who initiated AET. AET adherence was captured using validated items. Data regarding patient (e.g., race), medication-related (e.g., symptoms), cancer care delivery (e.g., communication), and clinicopathologic factors (e.g., chemotherapy) were collected via surveys and medical charts. Multivariable logistic regression models were employed to calculate odds ratios and 95% confidence intervals (CIs) associated with adherence. RESULTS Of the 570 participants, 92% were privately insured and nearly one of three were Black. Thirty-six percent reported nonadherent behaviors. In multivariable analysis, women less likely to report adherent behaviors were Black (vs. White; OR, 0.43; 95% CI, 0.27-0.67; P < 0.001) and with greater symptom burden (OR, 0.98; 95% CI, 0.96-1.00; P < 0.05). Participants more likely to be adherent were overweight (vs. normal weight) (OR, 1.58; 95% CI, 1.04-2.43; P < 0.05), sat ≤ 6 hours a day (vs. ≥6 hours; OR, 1.83; 95% CI, 1.25-2.70; P < 0.01), and were taking aromatase inhibitors (vs. tamoxifen; OR, 1.91; 95% CI, 1.28-2.87; P < 0.01). CONCLUSIONS Racial differences in AET adherence were observed. Longitudinal assessments of symptom burden are needed to better understand this dynamic process and factors that may explain differences in survivor subgroups. IMPACT Future interventions should prioritize Black survivors and women with greater symptom burden.
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Affiliation(s)
- Vanessa B Sheppard
- Department of Health Behavior and Policy, Virginia Commonwealth University School of Medicine, Richmond, Virginia.
- Office of Health Equity and Disparities Research, VCU Massey Cancer Center, Richmond, Virginia
| | - Arnethea L Sutton
- Department of Health Behavior and Policy, Virginia Commonwealth University School of Medicine, Richmond, Virginia
| | | | - Jun He
- Department of Health Sciences Research, Mayo Clinic, Rochester, Minnesota
| | - Bassam Dahman
- Department of Health Behavior and Policy, Virginia Commonwealth University School of Medicine, Richmond, Virginia
| | - Megan C Edmonds
- Department of Health Behavior and Policy, Virginia Commonwealth University School of Medicine, Richmond, Virginia
| | - Mary Helen Hackney
- Department of Internal Medicine, Virginia Commonwealth University School of Medicine, Richmond, Virginia
| | - Mahlet G Tadesse
- Department of Mathematics and Statistics, Georgetown University, Washington, DC
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Abstract
Purpose of Review This paper aims to summarize the data of recently completed and key ongoing clinical trials of systemic agents for advanced hepatocellular carcinoma (aHCC). In particular, the review focuses on ongoing checkpoint inhibitor combination trials and promising studies combining tyrosine kinase inhibitors with checkpoint inhibitors. Recent Findings The recently approved combination of atezolizumab and bevacizumab based on the IMbrave150 trial has shown the most potential with the highest overall survival of any systemic agent in HCC to date, surpassing sorafenib. Despite COVID-19 delays, other promising trials that involve combining VEGF-directed therapy and checkpoint inhibition, cancer vaccines, phosphatidylserine, YIV-906, and oncolytic and immunotherapeutic vaccinia virus are actively recruiting patients. Summary After almost a 10-year dormancy, the list of potential systemic treatment options for aHCC is growing rapidly. Given the promising data from the IMbrave150 trial, the combination of atezolizumab and bevacizumab is now the new first-line therapy. We discuss the change in landscape, the new second- and third-line systemic treatments in aHCC, and the ongoing clinical trials for newer agents including combination therapies.
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Affiliation(s)
| | - Anjana Pillai
- Division of Gastroenterology, University of Chicago, Chicago, IL USA
| | - Bassam Dahman
- Department of Health Behavior and Policy, Virginia Commonwealth University, Richmond, VA USA
| | - Binu V John
- Division of Hepatology, Bruce W Carter VA Medical Center, Miami, FL 33125 USA
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Preston MA, Ross L, Chukmaitov A, Smith SA, Odlum ML, Dahman B, Sheppard VB. Health Insurance Coverage Mandates: Colorectal Cancer Screening in the Post-ACA Era. Cancer Prev Res (Phila) 2020; 14:123-130. [PMID: 32917646 DOI: 10.1158/1940-6207.capr-20-0028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2020] [Revised: 07/30/2020] [Accepted: 09/02/2020] [Indexed: 11/16/2022]
Abstract
Building a culture of precision public health requires research that includes health delivery model with innovative systems, health policies, and programs that support this vision. Health insurance mandates are effective mechanisms that many state policymakers use to increase the utilization of preventive health services, such as colorectal cancer screening. This study estimated the effects of health insurance mandate variations on colorectal cancer screening post Affordable Care Act (ACA) era. The study analyzed secondary data from the Behavioral Risk Factor Surveillance System (BRFSS) and the NCI State Cancer Legislative Database (SCLD) from 1997 to 2014. BRFSS data were merged with SCLD data by state ID. The target population was U.S. adults, age 50 to 74, who lived in states where health insurance was mandated or nonmandated before and after the implementation of ACA. Using a difference-in-differences (DD) approach with a time-series analysis, we evaluated the effects of health insurance mandates on colorectal cancer screening status based on U.S. Preventive Services Task Force guidelines. The adjusted average marginal effects from the DD model indicate that health insurance mandates increased the probability of up-to-date screenings versus noncompliance by 2.8% points, suggesting that an estimated 2.37 million additional age-eligible persons would receive a screening with such health insurance mandates. Compliant participants' mean age was 65 years and 57% were women (n = 32,569). Our findings are robust for various model specifications. Health insurance mandates that lower out-of-pocket expenses constitute an effective approach to increase colorectal cancer screenings for the population, as a whole. PREVENTION RELEVANCE: The value added includes future health care reforms that increase access to preventive services, such as CRC screening, are likely with lower out-of-pocket costs and will increase the number of people who are considered "up-to-date". Such policies have been used historically to improve health outcomes, and they are currently being used as public health strategies to increase access to preventive health services in an effort to improve the nation's health.
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Affiliation(s)
- Michael A Preston
- Department of Health Behavior and Policy, Virginia Commonwealth University, Richmond, Virginia. .,Department of Health Behavior and Policy, Office of Health Equity & Disparities Research, VCU Massey Cancer Center, Virginia Commonwealth University, Richmond, Virginia
| | - Levi Ross
- Department of Health Science, The University of Alabama, Tuscaloosa, Alabama
| | - Askar Chukmaitov
- Department of Health Behavior and Policy, Virginia Commonwealth University, Richmond, Virginia
| | - Sharla A Smith
- Department of Population Health, University of Kansas School of Medicine-Wichita, Wichita, Kansas
| | | | - Bassam Dahman
- Department of Health Behavior and Policy, Virginia Commonwealth University, Richmond, Virginia
| | - Vanessa B Sheppard
- Department of Health Behavior and Policy, Virginia Commonwealth University, Richmond, Virginia.,Department of Health Behavior and Policy, Office of Health Equity & Disparities Research, VCU Massey Cancer Center, Virginia Commonwealth University, Richmond, Virginia
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John BV, Aubuchon S, Dahman B, Konjeti VR, Heuman D, Hubert J, Thomas S, Deng Y, Solomon C, Sundaram LT, Love E, Singal AG, Tatum JL. Addition of [ 18 F]Fluorodeoxyglucose Positron Emission Tomography With Computed Tomography to Cross-Sectional Imaging Improves Staging and Alters Management in Hepatocellular Carcinoma. Liver Transpl 2020; 26:774-784. [PMID: 32128966 PMCID: PMC8006185 DOI: 10.1002/lt.25743] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2019] [Revised: 01/30/2020] [Accepted: 02/17/2020] [Indexed: 12/13/2022]
Abstract
In this work, we characterize the value of positron emission tomography (PET) with computed tomography (CT) in combination with cross-sectional imaging for staging and prognostication of hepatocellular carcinoma (HCC) patients. In this retrospective cohort study, HCC patients underwent PET-CT after initial staging with contrast-enhanced CT or magnetic resonance imaging (MRI). The benefit of PET-CT was measured by the identification of new HCC lesions, and potential harm was quantified by the number of false positives and subsequent diagnostic evaluation. We used multivariate Cox regression analysis to evaluate the association between the highest grade on PET-CT with the risk of extrahepatic metastasis, progression-free, and overall survival. Among 148 patients, PET-CT detected additional extrahepatic metastasis in 11.9% of treatment-naïve and 13.8% of treatment-experienced patients. PET-CT changed the Barcelona Clinic Liver Cancer (BCLC) staging in 5.9% of treatment-naïve and 18.8% of treatment-experienced patients compared with CT/MRI alone, changing HCC management in 9.9% and 21.3% of patients, respectively. Of the patients, 5% (n = 8) experienced severe physical harm requiring additional procedures to evaluate extrahepatic findings. High tumor grade on PET-CT was independently associated with a higher likelihood of extrahepatic metastasis (hazard ratio [HR], 17.1; 95% confidence interval [CI], 3.6-81.5) and worse overall survival (HR, 2.4; 95% CI, 1.4-4.3). Treatment-experienced patients (versus treatment-naïve patients; HR, 9.7; 95% CI, 1.9-49.4) and BCLC stage A (HR, 8.2; 95% CI, 1.5-45.9; P < 0.01) and BCLC stage B (HR, 20.6; 95% CI, 1.5-282.2; P < 0.05) were more likely to have an upstaging with PET-CT compared with BCLC stage C (reference). PET-CT provides prognostic information and improves tumor staging beyond CT/MRI alone, with subsequent changes in management for patients with HCC.
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Affiliation(s)
- Binu V. John
- Department of Hepatology, Miami Veterans Affairs Medical Center, Miami, FL
| | - Sean Aubuchon
- Virginia Commonwealth University School of Medicine, Richmond, VA
| | - Bassam Dahman
- Department of Health Behavior and Policy, Virginia Commonwealth University, Richmond, VA
| | | | - Douglas Heuman
- Department of Gastroenterology and Hepatology, McGuire Veterans Affairs Medical Center, Richmond, VA
| | - Jennifer Hubert
- Department of Radiology and Nuclear Medicine, McGuire Veterans Affairs Medical Center, Richmond, VA
| | - Smitha Thomas
- Department of Radiology and Nuclear Medicine, McGuire Veterans Affairs Medical Center, Richmond, VA
| | - Yangyang Deng
- Department of Health Behavior and Policy, Virginia Commonwealth University, Richmond, VA
| | - Cynthia Solomon
- Department of Gastroenterology and Hepatology, McGuire Veterans Affairs Medical Center, Richmond, VA
| | - Latha Thankam Sundaram
- Department of Gastroenterology and Hepatology, McGuire Veterans Affairs Medical Center, Richmond, VA
| | - Eleanor Love
- Virginia Commonwealth University School of Medicine, Richmond, VA
| | - Amit G. Singal
- Division of Digestive and Liver Diseases, University of Texas Southwestern Medical Center, Dallas, TX
| | - James L. Tatum
- Department of Radiology and Nuclear Medicine, McGuire Veterans Affairs Medical Center, Richmond, VA
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Miller CA, Guidry JPD, Dahman B, Thomson MD. A Tale of Two Diverse Qualtrics Samples: Information for Online Survey Researchers. Cancer Epidemiol Biomarkers Prev 2020; 29:731-735. [PMID: 32066616 DOI: 10.1158/1055-9965.epi-19-0846] [Citation(s) in RCA: 66] [Impact Index Per Article: 16.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2019] [Revised: 10/23/2019] [Accepted: 02/11/2020] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND There is often a lack of transparency in research using online panels related to recruitment methods and sample derivation. The purpose of this study was to describe the recruitment and participation of respondents from two disparate surveys derived from the same online research panel using quota sampling. METHODS A commercial survey sampling and administration company, Qualtrics, was contracted to recruit participants and implement two Internet-based surveys. The first survey targeted adults aged 50 to 75 years and used sampling quotas to obtain diversity with respect to household income and race/ethnicity. The second focused on women aged 18 to 49 years and utilized quota sampling to achieve a geographically balanced sample. RESULTS A racially and economically diverse sample of older adults (n = 419) and a geographically diverse sample of younger women (n = 530) were acquired relatively quickly (within 12 and 4 days, respectively). With exception of the highest income level, quotas were implemented as requested. Recruitment of older adults took longer (vs. younger female adults). Although survey completion rates were reasonable in both studies, there were inconsistencies in the proportion of incomplete survey responses and quality fails. CONCLUSIONS Cancer researchers, and researchers in general, should consider ways to leverage the use of online panels for future studies. To optimize novel and innovative strategies, researchers should proactively ask questions about panels and carefully consider the strengths and drawbacks of online survey features including quota sampling and forced response. IMPACT Results provide practical insights for cancer researchers developing future online surveys and recruitment protocols.See all articles in this CEBP Focus section, "Modernizing Population Science."
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Affiliation(s)
- Carrie A Miller
- Department of Health Behavior and Policy, Virginia Commonwealth University, Richmond, Virginia.
| | - Jeanine P D Guidry
- Robertson School of Media and Culture, Virginia Commonwealth University, Richmond, Virginia
| | - Bassam Dahman
- Department of Health Behavior and Policy, Virginia Commonwealth University, Richmond, Virginia
| | - Maria D Thomson
- Department of Health Behavior and Policy, Virginia Commonwealth University, Richmond, Virginia
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Abstract
OBJECTIVES This study investigated the relationship between state Medicaid co-payment policies and cancer screening for Medicaid-enrolled women. STUDY DESIGN Cross-sectional analysis of administrative claims and enrollment data. METHODS Our data included Medicaid Analytic eXtract (MAX) outpatient claims files across 43 states in 2003, 2008, and 2010, the years for which both MAX data and state cost-sharing data were available. Data on enrollee demographics and screening services from enrollment and claims files were merged with state-year data on co-payment policies and county-level controls from the Area Health Resources File. Participants were nonelderly, nondisabled, nonpregnant women in the recommended age range for each screening service (50-64 years for mammograms; 21-64 years for Pap tests) enrolled in fee-for-service Medicaid. The main independent variable is whether an enrollee faced cost sharing for preventive services. We examined 3 categories of cost sharing: co-payments for all visits, including for preventive services; co-payments for outpatient visits but waived for preventive services; and no co-payments. The main outcome measure was receipt of mammogram or Pap test within a 12-month period. RESULTS Medicaid enrollees with co-payments for preventive services were less likely to receive both screening mammograms and Pap tests than enrollees in states not requiring cost sharing for preventive services. CONCLUSIONS Co-payments for preventive services discourage breast and cervical cancer screening among Medicaid enrollees. The effect is larger for breast cancer screening, which is costlier and requires an additional visit. Considering this evidence, cost sharing for preventive services may lead to adverse health consequences and greater long-term costs.
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Affiliation(s)
- Lindsay M Sabik
- Department of Health Policy and Management, University of Pittsburgh, 130 De Soto St, A613, Pittsburgh, PA 15261.
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Smith WR, McClish DK, Roberts JD, Kandalaft O, Dahman B, Knisely J, Levenson J, Roseff S, Aisiku IP. Prescription Opioid Misuse Index in sickle cell patients: A brief questionnaire to assess at-risk for opioid abuse. J Opioid Manag 2019; 15:323-331. [PMID: 31637684 DOI: 10.5055/jom.2019.0517] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
OBJECTIVE To develop a survey instrument to identify adult sickle cell disease (SCD) patients on chronic opioid therapy who are at-risk for opioid abuse. DESIGN Prospective survey and interview. SETTING Adult SCD clinic in a large urban teaching facility. PATIENTS/PARTICIPANTS Convenience sampling of adult patients presenting to the sickle cell clinic. INTERVENTIONS None. MAIN OUTCOME Primary outcome was "at-risk for opioid misuse," defined as at least 3/8 "yes" answers (a positive composite score) on the Prescription Opioid Misuse Index (POMI) questionnaire. Secondary outcome was DSM-IV criteria for substance abuse using the DSM IV Diagnostic Interview Schedule. RESULTS Of the 99 patients who completed the POMI, the mean age was 36 years; 58.6 percent were female, 48 percent were hemoglobin SS (47/99), and 26 percent were SC (26/99). Twenty-four percent (24/99) were identified as at-risk for opioid misuse using the POMI. There were no differences in demographic, SCD genotype, or socioeconomic variables for at-risk versus not-at-risk patients. CONCLUSION Twenty-four percent of unselected adult SCD patients on opioids were identified as at-risk for opioid misuse using a quick survey. This may represent as much as 2.5-7 times the national misuse rate. This group of patients may benefit from additional diagnostic and therapeutic interventions to help understand and manage their opioid usage.
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Affiliation(s)
- Wally R Smith
- Professor, Department of Medicine, Virginia Commonwealth University, Richmond, Virginia
| | - Donna K McClish
- Professor, Department of Biostatistics, Virginia Commonwealth University, Richmond, Virginia
| | - John D Roberts
- Professor, Department of Medicine, Yale University, New Haven, Connecticut
| | - Osama Kandalaft
- Department of Internal Medicine, Baystate Medical Center, Springfield, Massachusetts
| | - Bassam Dahman
- Assistant Professor, Department of Healthcare Policy and Research, Virginia Commonwealth University, Richmond, Virginia
| | - Janet Knisely
- Associate Professor, Department of Psychiatry, Virginia Commonwealth University, Richmond, Virginia
| | - James Levenson
- Professor, Department of Psychiatry, Virginia Commonwealth University, Richmond, Virginia
| | - Susan Roseff
- Professor, Department of Pathology, Virginia Commonwealth University, Richmond, Virginia
| | - Imo P Aisiku
- Assistant Professor, Department of Emergency Medicine, Brigham and Women's Hospital, Boston, Massachusetts
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Slade AN, Dahman B, Chang MG. Racial differences in the PSA bounce in predicting prostate cancer outcomes after brachytherapy: Evidence from the Department of Veterans Affairs. Brachytherapy 2019; 19:6-12. [PMID: 31611160 DOI: 10.1016/j.brachy.2019.08.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2019] [Revised: 08/14/2019] [Accepted: 08/19/2019] [Indexed: 11/28/2022]
Abstract
PURPOSE African American men have historically had poorer prostate cancer biochemical and survival outcomes than Caucasians. However, emerging data suggest nononcologic factors drive much of this disparity. Prior evidence has suggested an association between a transient prostate specific antigen (PSA) bounce and improved biochemical control. However, racial differences in this relationship have remained relatively unexplored. METHODS AND MATERIALS We identified 4477 men treated for low- or intermediate-risk prostate cancer within the U.S. Department of Veterans Affairs (VA) from 2000 to 2010 with brachytherapy alone or in combination with external beam radiotherapy without androgen deprivation. Longitudinal PSA data were used to define to biochemical failure and PSA bounce. Cox proportional hazard models were used explore racial differences in the relationship between the PSA bounce and time to biochemical failure. RESULTS Thirty-one percent of our sample experienced a PSA bounce, with African Americans more likely to experience a bounce (42%) compared with Caucasians (29%); p < 0.001. Despite this, African Americans had a higher likelihood of biochemical failure (hazard ratio [HR] 1.4; p = 0.006). However, African American men experiencing a PSA bounce were less likely to experience a biochemical failure (HR = 0.64; p = 0.046), whereas this relationship was not statistically significant for Caucasians (HR = 0.78; p = 0.092). On multivariate analysis, African Americans receiving brachytherapy alone were most sensitive to the protective benefit of the PSA bounce (HR = 0.64). CONCLUSIONS A PSA bounce was associated with improved biochemical control among patients receiving brachytherapy as part of their treatment for low- or intermediate-risk prostate cancer at the VA. African American men treated with brachytherapy had a particularly pronounced biochemical control benefit of a PSA bounce.
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Affiliation(s)
- Alexander N Slade
- Department of Radiation Oncology, Virginia Commonwealth University Health System, Massey Cancer Center, Richmond, VA.
| | - Bassam Dahman
- Department of Health Behavior and Policy, Virginia Commonwealth University, Richmond, VA
| | - Michael G Chang
- Department of Radiation Oncology, Virginia Commonwealth University Health System, Massey Cancer Center, Richmond, VA; Department of Radiation Oncology, Hunter Holmes McGuire VA Medical Center, Richmond VA
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Masiano SP, Green TL, Dahman B, Kimmel AD. The effects of community-based distribution of family planning services on contraceptive use: The case of a national scale-up in Malawi. Soc Sci Med 2019; 238:112490. [PMID: 31437769 DOI: 10.1016/j.socscimed.2019.112490] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2018] [Revised: 07/17/2019] [Accepted: 08/10/2019] [Indexed: 11/19/2022]
Abstract
RATIONALE Although many sub-Saharan African countries have scaled-up pilot projects of community-based distribution (CBD) of family planning services, the effects of the scaled-up CBDs on contraceptive use remain unclear. OBJECTIVE We leveraged a national scale-up of Malawi's Learning and Innovation Population and Family Planning pilot to evaluate the effects of a scale-up of CBDs on contraceptive use. We also investigated whether education and income, two important determinants of contraceptive use behaviors, moderate the effects of the scaled-up CBDs. METHOD We used the 2000/2004 and 2010/2016 Malawi Demographic and Health Surveys (N = 57,978) and difference-in-differences analyses to estimate the effects of the 2005 national scale-up of CBDs on modern contraceptive use. We used rural and urban communities as the intervention and comparison groups because the national CBDs were implemented only in rural communities. Contraceptive use is defined as the current use of any modern contraceptive method (e.g., pills) and was modelled using multilevel logistic regression. RESULTS Prior to the implementation of the national scale CBDs (2000/2004), the probability of using contraceptives was 21.5% in rural communities and 26.3% in urban communities. After the scale-up (2010/2016), the probability of using contraceptives increased in both rural and urban communities but was greater in rural communities (44.9% vs. 42.9%). The effect attributable to the national scale CBDs was 6.8 percentage points (95% CI [3.3, 9.7]). The effects of the national CBDs were greater among uneducated and low-income women. CONCLUSIONS These findings suggest that national CBDs increase overall contraceptive use, particularly in rural communities, and that poor and uneducated women benefit more from family planning interventions that reduce communication and financial barriers.
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Affiliation(s)
- Steven P Masiano
- Department of Health Behavior and Policy, Virginia Commonwealth University School of Medicine, Richmond, VA, USA; Baylor College of Medicine Children's Foundation Malawi, Lilongwe, Malawi.
| | - Tiffany L Green
- Department of Health Behavior and Policy, Virginia Commonwealth University School of Medicine, Richmond, VA, USA
| | - Bassam Dahman
- Department of Health Behavior and Policy, Virginia Commonwealth University School of Medicine, Richmond, VA, USA
| | - April D Kimmel
- Department of Health Behavior and Policy, Virginia Commonwealth University School of Medicine, Richmond, VA, USA
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Chukmaitov A, Dahman B, Bradley CJ. Outpatient facility volume, facility type, and the risk of serious colonoscopy-related adverse events in patients with comorbid conditions: a population-based study. Int J Colorectal Dis 2019; 34:1203-1210. [PMID: 31093737 DOI: 10.1007/s00384-019-03304-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/25/2019] [Indexed: 02/04/2023]
Abstract
PURPOSE Patients with a chronic comorbidity or multiple comorbidities are at much greater risk of serious colonoscopy-related gastrointestinal (GI) adverse events relative to patients with no comorbidity. It is important to identify outpatient facilities that can effectively and safely provide colonoscopy to complex patients. To address this need, the association between outpatient facilities' complex care volume and type (ambulatory surgery center (ASC) and hospital outpatient department (HOPD)) and the risks of serious GI adverse events in colonoscopy patients with single and multiple chronic comorbidities were examined. METHODS Outpatient colonoscopies of 1,020,372 patients with single and multiple comorbidities were investigated, using a retrospective cohort study. Thirty-day hospitalizations due to colonic perforations and GI bleeding were examined. Ambulatory surgery and hospital discharge datasets from California, Florida, and New York for 2006-2009 were used. RESULTS Higher complex care volume was associated with lower risks of adverse events in patients with comorbidities (OR 1.69; 95% CI [1.13, 2.54]). ASCs had higher risks of adverse events in patients with comorbidities relative to HOPDs (OR 2.85; 95% CI [2.40, 3.38]). Patients with single and multiple comorbid conditions, patients with systemic diseases, and complex patients of advanced age had higher risks of adverse events. CONCLUSIONS Referring patients with single and multiple chronic comorbidities to facilities experienced in treating complex patients, or HOPDs, may reduce colonoscopy-related adverse events.
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Affiliation(s)
- Askar Chukmaitov
- Department of Health Behavior and Policy, School of Medicine, Virginia Commonwealth University and VCU Massey Cancer Center, P.O. Box 980430, Richmond, VA, 23298-0430, USA.
| | - Bassam Dahman
- Department of Health Behavior and Policy, School of Medicine, Virginia Commonwealth University and VCU Massey Cancer Center, P.O. Box 980430, Richmond, VA, 23298-0430, USA
| | - Cathy J Bradley
- Cancer Prevention and Control, Colorado School of Public Health and University of Colorado Comprehensive Cancer Center, 1665 Aurora Ct, Aurora, CO, 80045, USA
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