High-Acuity Alcohol-Related Complications During the COVID-19 Pandemic

Importance

Research has demonstrated an association between the COVID-19 pandemic and increased alcohol-related liver disease hospitalizations and deaths. However, trends in alcohol-related complications more broadly are unclear, especially among subgroups disproportionately affected by alcohol use.

Objective

To assess trends in people with high-acuity alcohol-related complications admitted to the emergency department, observation unit, or hospital during the COVID-19 pandemic, focusing on demographic differences.

Design, Setting, and Participants

This longitudinal interrupted time series cohort study analyzed US national insurance claims data using Optum's deidentified Clinformatics Data Mart database from March 2017 to September 2021, before and after the March 2020 COVID-19 pandemic onset. A rolling cohort of people 15 years and older who had at least 6 months of continuous commercial or Medicare Advantage coverage were included. Subgroups of interest included males and females stratified by age group. Data were analyzed from April 2023 to January 2024.

Exposure

COVID-19 pandemic environment from March 2020 to September 2021.

Main Outcomes and Measures

Differences between monthly rates vs predicted rates of high-acuity alcohol-related complication episodes, determined using claims-based algorithms and alcohol-specific diagnosis codes. The secondary outcome was the subset of complication episodes due to alcohol-related liver disease.

Results

Rates of high-acuity alcohol-related complications were statistically higher than expected in 4 of 18 pandemic months after March 2020 (range of absolute and relative increases: 0.4-0.8 episodes per 100 000 people and 8.3%-19.4%, respectively). Women aged 40 to 64 years experienced statistically significant increases in 10 of 18 pandemic months (range of absolute and relative increases: 1.3-2.1 episodes per 100 000 people and 33.3%-56.0%, respectively). In this same population, rates of complication episodes due to alcohol-related liver disease increased above expected in 16 of 18 pandemic months (range of absolute and relative increases: 0.8-2.1 episodes per 100 000 people and 34.1%-94.7%, respectively).

Conclusions and Relevance

In this cohort study of a national, commercially insured population, high-acuity alcohol-related complication episodes increased beyond what was expected in 4 of 18 COVID-19 pandemic months. Women aged 40 to 64 years experienced 33.3% to 56.0% increases in complication episodes in 10 of 18 pandemic months, a pattern associated with large and sustained increases in high-acuity alcohol-related liver disease complications. Findings underscore the need for increased attention to alcohol use disorder risk factors, alcohol use patterns, alcohol-related health effects, and alcohol regulations and policies, especially among women aged 40 to 64 years.

Acute Diabetes Complications After Transition to a Value-Based Medication Benefit

Importance

The association of value-based medication benefits with diabetes health outcomes is uncertain.

Objective

To assess the association of a preventive drug list (PDL) value-based medication benefit with acute, preventable diabetes complications.

Design, Setting, and Participants

This cohort study used a controlled interrupted time series design and analyzed data from a large, national, commercial health plan from January 1, 2004, through June 30, 2017, for patients with diabetes aged 12 to 64 years enrolled through employers that adopted PDLs (intervention group) and matched and weighted members with diabetes whose employers did not adopt PDLs (control group). All participants were continuously enrolled and analyzed for 1 year before and after the index date. Subgroup analysis assessed patients with diabetes living in lower-income and higher-income neighborhoods. Data analysis was performed between August 19, 2020, and December 1, 2023.

Exposure

At the index date, intervention group members experienced employer-mandated enrollment in a PDL benefit that was added to their follow-up year health plan. This benefit reduced out-of-pocket costs for common cardiometabolic drugs, including noninsulin antidiabetic agents and insulin. Matched control group members continued to have cardiometabolic medications subject to deductibles or co-payments at follow-up.

Main Outcomes and Measures

The primary outcome was acute, preventable diabetes complications (eg, bacterial infections, neurovascular events, acute coronary disease, and diabetic ketoacidosis) measured as complication days per 1000 members per year. Intermediate measures included the proportion of days covered by and higher use (mean of 1 or more 30-day fills per month) of antidiabetic agents.

Results

The study 10 588 patients in the intervention group (55.2% male; mean [SD] age, 51.1 [10.1] years) and 690 075 patients in the control group (55.2% male; mean [SD] age, 51.1 [10.1] years) after matching and weighting. From baseline to follow-up, the proportion of days covered by noninsulin antidiabetic agents increased by 4.7% (95% CI, 3.2%-6.2%) in the PDL group and by 7.3% (95% CI, 5.1%-9.5%) among PDL members from lower-income areas compared with controls. Higher use of noninsulin antidiabetic agents increased by 11.3% (95% CI, 8.2%-14.5%) in the PDL group and by 15.2% (95% CI, 10.6%-19.8%) among members of the PDL group from lower-income areas compared with controls. The PDL group experienced an 8.4% relative reduction in complication days (95% CI, -13.9% to -2.8%; absolute reduction, -20.2 [95% CI, -34.3 to -6.2] per 1000 members per year) compared with controls from baseline to follow-up, while PDL members residing in lower-income areas had a 10.2% relative reduction (95% CI, -17.4% to -3.0%; absolute, -26.1 [95% CI, -45.8 to -6.5] per 1000 members per year).

Conclusions and Relevance

In this cohort study, acute, preventable diabetes complication days decreased by 8.4% in the overall PDL group and by 10.2% among PDL members from lower-income areas compared with the control group. The results may support a strategy of incentivizing adoption of targeted cost-sharing reductions among commercially insured patients with diabetes and lower income to enhance health outcomes.

Quantifying cancer risk from exposures to medical imaging in the Risk of Pediatric and Adolescent Cancer Associated with Medical Imaging (RIC) Study: research methods and cohort profile

PURPOSE

The Risk of Pediatric and Adolescent Cancer Associated with Medical Imaging (RIC) Study is quantifying the association between cumulative radiation exposure from fetal and/or childhood medical imaging and subsequent cancer risk. This manuscript describes the study cohorts and research methods.

METHODS

The RIC Study is a longitudinal study of children in two retrospective cohorts from 6 U.S. healthcare systems and from Ontario, Canada over the period 1995-2017. The fetal-exposure cohort includes children whose mothers were enrolled in the healthcare system during their entire pregnancy and followed to age 20. The childhood-exposure cohort includes children born into the system and followed while continuously enrolled. Imaging utilization was determined using administrative data. Computed tomography (CT) parameters were collected to estimate individualized patient organ dosimetry. Organ dose libraries for average exposures were constructed for radiography, fluoroscopy, and angiography, while diagnostic radiopharmaceutical biokinetic models were applied to estimate organ doses received in nuclear medicine procedures. Cancers were ascertained from local and state/provincial cancer registry linkages.

RESULTS

The fetal-exposure cohort includes 3,474,000 children among whom 6,606 cancers (2394 leukemias) were diagnosed over 37,659,582 person-years; 0.5% had in utero exposure to CT, 4.0% radiography, 0.5% fluoroscopy, 0.04% angiography, 0.2% nuclear medicine. The childhood-exposure cohort includes 3,724,632 children in whom 6,358 cancers (2,372 leukemias) were diagnosed over 36,190,027 person-years; 5.9% were exposed to CT, 61.1% radiography, 6.0% fluoroscopy, 0.4% angiography, 1.5% nuclear medicine.

CONCLUSION

The RIC Study is poised to be the largest study addressing risk of childhood and adolescent cancer associated with ionizing radiation from medical imaging, estimated with individualized patient organ dosimetry.

Risk factors for suicide attempt in children, adolescents, and young adults hospitalized for mental health disorders

BACKGROUND

Suicide is a leading cause of death among children, adolescents, and young adults (AYA), and mental health disorders are a major contributing factor. Yet, suicidal behaviors among children and AYA with mental health concerns remain understudied and age-specific risk factors are poorly understood. We examined the risk factors for suicide attempt in children and AYA with mental health disorders across three age groups: pre-adolescent children (aged ≤ 12), adolescents (aged 13-17), and young adults (aged 18-25).

METHODS

A cross-sectional study of children and AYA hospitalized for a mental health disorder (n = 18,018) at a private hospital system with 141 facilities across the United States (year 2014).

RESULTS

Suicide attempts six months prior to hospitalization were reported in 12.1% (n = 177) pre-adolescent children, 22% (n = 1476) adolescents, and 17.9% (n = 1766) young adults. Evidence of psychological trauma was present in 55.4% of pre-adolescent children, 51.2% of adolescents, and 44.5% of young adults. Predictors for suicide attempt observed across all three age groups included the following: female sex, depressive disorder, and being a victim of bullying. Risk factors for suicide attempt specific to pre-adolescent children included being uninsured and having an unsafe home or school environment. Among AYA, suicide attempt was associated with non-Hispanic white, family history of suicide, emotional traumas, and other traumatic experiences. Alcohol use disorder was also a significant predictor of suicide attempt in young adults.

CONCLUSIONS

Suicide attempts among children and AYA admitted to a hospital with mental health concerns are highly prevalent. Socioeconomic stressors appeared to be an important contributing factor of suicidal behavior in pre-adolescent children but not in older AYA. Effective suicide prevention strategies targeting children and AYA would need to consider age-specific risk factors.

Trends in Outpatient Antibiotic Use in 3 Health Plans

OBJECTIVES

Previous analyses of data from 3 large health plans suggested that the substantial downward trend in antibiotic use among children appeared to have attenuated by 2010. Now, data through 2014 from these same plans allow us to assess whether antibiotic use has declined further or remained stable.

METHODS

Population-based antibiotic-dispensing rates were calculated from the same health plans for each study year between 2000 and 2014. For each health plan and age group, we fit Poisson regression models allowing 2 inflection points. We calculated the change in dispensing rates (and 95% confidence intervals) in the periods before the first inflection point, between the first and second inflection points, and after the second inflection point. We also examined whether the relative contribution to overall dispensing rates of common diagnoses for which antibiotics were prescribed changed over the study period.

RESULTS

We observed dramatic decreases in antibiotic dispensing over the 14 study years. Despite previous evidence of a plateau in rates, there were substantial additional decreases between 2010 and 2014. Whereas antibiotic use rates decreased overall, the fraction of prescribing associated with individual diagnoses was relatively stable. Prescribing for diagnoses for which antibiotics are clearly not indicated appears to have decreased.

CONCLUSIONS

These data revealed another period of marked decline from 2010 to 2014 after a relative plateau for several years for most age groups. Efforts to decrease unnecessary prescribing continue to have an impact on antibiotic use in ambulatory practice.

Predictors of timing of transfer from pediatric- to adult-focused primary care

IMPORTANCE

A timely, well-coordinated transfer from pediatric- to adult-focused primary care is an important component of high-quality health care, especially for youths with chronic health conditions. Current recommendations suggest that primary-care transfers for youths occur between 18 and 21 years of age. However, the current epidemiology of transfer timing is unknown.

OBJECTIVE

To examine the timing of transfer to adult-focused primary care providers (PCPs), the time between last pediatric-focused and first adult-focused PCP visits, and the predictors of transfer timing.

DESIGN, SETTING, AND PARTICIPANTS

Retrospective cohort study of patients insured by Harvard Pilgrim Health Care (HPHC), a large not-for-profit health plan. Our sample included 60 233 adolescents who were continuously enrolled in HPHC from 16 to at least 18 years of age between January 2000 and December 2012. Pediatric-focused PCPs were identified by the following provider specialty types, but no others: pediatrics, adolescent medicine, or pediatric nurse practitioner. Adult-focused PCPs were identified by having any provider type that sees adult patients. Providers with any specialty provider designation (eg, gastroenterology or gynecology) were not considered PCPs.

MAIN OUTCOMES AND MEASURES

We used multivariable Cox proportional hazards regression to model age at first adult-focused PCP visit and time from the last pediatric-focused to the first adult-focused PCP visit (gap) for any type of office visit and for those that were preventive visits.

RESULTS

Younger age at transfer was observed for female youths (hazard ratio [HR], 1.32 [95% CI, 1.29-1.36]) who had complex (HR, 1.06 [95% CI, 1.01-1.11]) or noncomplex (HR, 1.08 [95% CI, 1.05-1.12]) chronic conditions compared with those who had no chronic conditions. Transfer occurred at older ages for youths who lived in lower-income neighborhoods compared with those who lived in higher-income neighborhoods (HR, 0.89 [95% CI, 0.83-0.95]). The gap between last pediatric-focused to first adult-focused PCP visit was shorter for female youths than male youths (HR, 1.57 [95% CI, 1.53-1.61]) and youths with complex (HR, 1.35 [95% CI, 1.28-1.41]) or noncomplex (HR, 1.24 [95% CI, 1.20-1.28]) chronic conditions. The gap was longer for youths living in lower-income neighborhoods than for those living in higher-income neighborhoods (HR, 0.80 [95% CI, 0.75-0.85]). Multivariable models showed an adjusted median age at transfer of 21.8 years for office visits and 23.1 years for preventive visits and an adjusted median gap length of 20.5 months for office visits and 41.6 months for preventive visits.

CONCLUSIONS AND RELEVANCE

Most youths are transferring care later than recommended and with gaps of more than a year. While youths with chronic conditions have shorter gaps, they may need even shorter transfer intervals to ensure continuous access to care. More work is needed to determine whether youths are experiencing clinically important lapses in care or other negative health effects due to the delayed timing of transfer.

Impact of 13-Valent Pneumococcal Conjugate Vaccination on Streptococcus pneumoniae Carriage in Young Children in Massachusetts

BACKGROUND

In April 2010, a 13-valent pneumococcal conjugate vaccine (PCV13) replaced PCV7 for use in the United States. We evaluated rates of pneumococcal colonization, by serotype and antibiotic resistance, in Massachusetts communities where serial cross-sectional surveillance has been conducted for the past decade.

METHODS

Nasopharyngeal swabs were obtained from children 0 to <7 years of age and seen by primary care providers for well child or acute illness visits in 2001, 2004, 2007, 2009, and 2011. Pneumococcal isolates were serotyped by Quellung reaction and classified as PCV7 serotypes (4, 6B, 9V, 14, 18C, 19F, 23F), additional PCV13 serotypes (1, 3, 5, 6A, 7F, 19A), or non-PCV13 serotypes. Changes in colonization and impact of PCV13 were assessed using generalized linear mixed models, adjusting for known risk factors and accounting for clustering by community.

RESULTS

Introduction of PCV13 did not affect the rate of overall pneumococcal colonization (31% in 2011). Colonization with non-PCV13 serotypes increased between 2001 and 2011 for all children (odds ratio [OR] per year, 1.12; 95% confidence interval [CI], 1.10, 1.15; P < .0001). 19A remained the second most common serotype in 2011, although a decline from 2009 was observed. Penicillin (7%), erythromycin (28%), ceftriaxone (10%), and clindamycin (10%) nonsusceptibility were commonly identified, concentrated among a small number of serotypes (including 19A, 35B, 15B/C, and 15A). Among healthy children 6-23 months old, colonization with PCV13 serotypes was lower among recipients of PCV13 vaccine (adjusted OR, 0.30; 95% CI, 0.11, 0.78). This effect was not observed in 6- to 23-month-old children with a concomitant respiratory tract infection (adjusted OR 1.36; 95% CI, 0.66, 2.77) or children 2 to <7 years old (adjusted OR, 1.17; 95% CI, 0.58, 2.34).

CONCLUSIONS

13-Valent pneumococcal conjugate vaccine reduced the prevalence of colonization with PCV13 serotypes among children 6-23 months old, but its efficacy was not shown among older children.

Questioning Care at the End of Life

BACKGROUND

The goal of the larger study was to explore physicians' emotional responses to the death of their patients; this study analyzed a subset of physician transcripts to elucidate the construct of questioning care, which emerged from the larger study.

OBJECTIVE

To analyzes how physicians question care-expressing concern, unease, or uncertainty about treatment decisions and practices, errors, or adverse events-as they attend dying patients.

DESIGN

Retrospective interview study of physicians caring for randomly selected deaths on the medical service of a major academic teaching hospital, using qualitative and quantitative measures. SETTING, SUBJECTS: 188 attendings, residents, and interns on the internal medical services of two academic medical centers were part of the larger study. A subsample of 75 physician narratives was selected for qualitative data analysis for this study.

MEASUREMENTS

Qualitative measures included open-ended questions eliciting physicians' stories of the most recent and a most emotionally powerful patient death they have experienced. Grounded theory was used to analyze physician narratives. Quantitative instruments measured physician attitudes toward end-of-life care and responses to the most recent and most emotional patient death.

RESULTS

Physicians question care more frequently in most emotional deaths (42%) than in most recent deaths (34%). Physicians question communication with patients and families and within medical teams, medical judgment and technique, standards of practice, and high-risk treatments, often assigning responsibility for medical management they perceive as inappropriate, futile, overly aggressive, or mistakes in judgment and technique. Responsibility ranges from the distal (the culture of medicine) to the proximal (personal). Frustration, guilt, and anger are more frequently expressed in these narratives when care is questioned.

CONCLUSIONS

A typology of questioning care emerged from these physicians' narratives that parallels and reflects recent and classic research on medical error and the culture of medicine. Physicians' questions about care can contribute to designing training experiences for residents and to improving the quality of systems that affect patients' experiences at life's end and physicians' experiences in caring for dying patients.

Narrative nuances on good and bad deaths: internists' tales from high-technology work places

Public and professional discourses in American society about what constitutes a "good death" have flourished in recent decades, as illustrated by the pivotal SUPPORT study and the growing palliative care movement. This paper examines a distinctive medical discourse from high-technology academic medical centers through an analysis of how physicians who are specialists in internal medicine tell stories about the deaths of patients in their care. 163 physicians from two major academic medical centers in the United States completed both qualitative open interviews and quantitative attitudinal measures on a recent death and on the most emotionally powerful death they experienced in the course of their careers. A subsample of 75 physicians is the primary source for the qualitative analysis, utilizing Atlas-ti."Good death" and "bad death" are common in popular discourse on death and dying. However, these terms are rarely used by physicians in this study when discussing specific patients and individual deaths. Rather, physicians' narratives are nuanced with professional judgments about what constitutes quality end-of-life care. Three major themes emerge from these narratives and frame the positive and negative characteristics of patient death. Time and Process: whether death was expected or unexpected, peaceful, chaotic or prolonged; Medical Care and Treatment Decisions: whether end-of-life care was rational and appropriate, facilitating a "peaceful" or "gentle" death, or futile and overly aggressive, fraught with irrational decisions or adverse events; Communication and Negotiation: whether communication with patients, family and medical teams was effective, leading to satisfying management of end-of-life care, or characterized by misunderstandings and conflict. When these physicians' narratives about patient deaths are compared with the classic sociological observations made by Glaser and Strauss in their study A Time for Dying (1968), historical continuities are evident as are striking differences associated with rapid innovation in medical technologies and a new language of medical futility. This project is part of a broader effort in American medicine to understand and improve end-of-life care.

Doctors' emotional reactions to recent death of a patient: cross sectional study of hospital doctors

OBJECTIVES

To describe doctors' emotional reactions to the recent death of an "average" patient and to explore the effects of level of training on doctors' reactions.

DESIGN

Cross sectional study using quantitative and qualitative data.

SETTING

Two academic teaching hospitals in the United States.

PARTICIPANTS

188 doctors (attending physicians (equivalent to UK consultants), residents (equivalent to UK senior house officers), and interns (equivalent to UK junior house officers)) who cared for 68 patients who died in the hospital.

MAIN OUTCOME MEASURES

Doctors' experiences in providing care, their emotional reactions to the patient's death, and their use of coping and social resources to manage their emotions.

RESULTS

Most doctors (139/188, 74%) reported satisfying experiences in caring for a dying patient. Doctors reported moderate levels of emotional impact (mean 4.7 (SD 2.4) on a 0-10 scale) from the death. Women and those doctors who had cared for the patient for a longer time experienced stronger emotional reactions. Level of training was not related to emotional reactions, but interns reported needing significantly more emotional support than attending physicians. Although most junior doctors discussed the patient's death with an attending physician, less than a quarter of interns and residents found senior teaching staff (attending physicians) to be the most helpful source of support.

CONCLUSIONS

Doctors who spend a longer time caring for their patients get to know them better but this also makes them more vulnerable to feelings of loss when these patients die. Medical teams may benefit from debriefing within the department to give junior doctors an opportunity to share emotional responses and reflect on the patient's death.