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Turrini G, Chan SS, Klein PW, Cohen SM, Stearns SC, Dempsey A, Hauck H, Cheever LW, Chappel AR. Assessing Health Care Utilization and Spending Among Older Medicare Beneficiaries With and Without HIV. Med Care Res Rev 2024; 81:280-289. [PMID: 37767861 DOI: 10.1177/10775587231198903] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/29/2023]
Abstract
Improvements in treatment have made HIV a manageable chronic condition, leading to increased life expectancy and a growing share of people with HIV who are older. Older people with HIV have higher rates of many chronic conditions, yet little is known about differences in health care utilization and spending. This study compared health care utilization and spending for Medicare beneficiaries with and without HIV, accounting for differential mortality. The data included demographic characteristics and claims-based information. Estimated cumulative spending for beneficiaries with HIV aged 67 to 77 years was 26% higher for Medicare Part A and 39% higher for Medicare Part B compared with beneficiaries without HIV; most of these differences would be larger if not for greater mortality risk among people with HIV (and therefore fewer years to receive care). Future research should disentangle underlying causes for this increased need and describe potential responses by policymakers and health care providers.
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Affiliation(s)
- Gina Turrini
- U.S. Department of Health and Human Services, Washington, DC, USA
| | - Stephanie S Chan
- U.S. Department of Health and Human Services, Washington, DC, USA
| | - Pamela W Klein
- U.S. Department of Health and Human Services, Rockville, MD, USA
| | - Stacy M Cohen
- U.S. Department of Health and Human Services, Rockville, MD, USA
| | | | - Antigone Dempsey
- U.S. Department of Health and Human Services, Rockville, MD, USA
| | - Heather Hauck
- U.S. Department of Health and Human Services, Rockville, MD, USA
| | - Laura W Cheever
- U.S. Department of Health and Human Services, Rockville, MD, USA
| | - Andre R Chappel
- U.S. Department of Health and Human Services, Washington, DC, USA
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Savitz ST, Falk K, Stearns SC, Grove LR, Pathman DE, Rossi JS. Race-ethnicity and sex differences in 1-year survival following percutaneous coronary intervention among Medicare fee-for-service beneficiaries. J Eval Clin Pract 2024; 30:406-417. [PMID: 38091249 DOI: 10.1111/jep.13954] [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: 05/02/2023] [Revised: 11/25/2023] [Accepted: 11/27/2023] [Indexed: 04/18/2024]
Abstract
RATIONALE Existing literature describing differences in survival following percutaneous coronary intervention (PCI) by patient sex, race-ethnicity and the role of socioeconomic characteristics (SEC) is limited. AIMS AND OBJECTIVES Evaluate differences in 1-year survival after PCI by sex and race-ethnicity, and explore the contribution of SEC to observed differences. METHODS Using a 20% sample of Medicare claims data for beneficiaries aged 65+, we identified fee-for-service patients who received PCI from 2007 to 2015. We performed logistic regression to assess how sex and race-ethnicity relate to procedural indication, inpatient versus outpatient setting, and 1-year mortality. We evaluated whether these relationships are moderated by sequentially controlling for factors including age, comorbidities, presence of acute myocardial infarction (AMI), county SEC, medical resource availability and inpatient versus outpatient procedural status. RESULTS We identified 300,491 PCI procedures, of which 94,863 (31.6%) were outpatient. There was a significant transition to outpatient PCI during the study period, especially for men compared with women and White patients compared with Black patients. Black patients were 3.50 percentage points (p < 0.001) and women were 3.41 percentage points (p < 0.001) more likely than White and male patients to undergo PCI at the time of AMI, which typically occurs in the inpatient setting. Controlling for age and calendar year, Black patients were 2.87 percentage points more likely than non-Hispanic White patients to die within 1 year after PCI. After controlling for Black-White differences in comorbidities, the differences in 1-year mortality decreased to 0.95 percentage points, which then became nonsignificant when further controlling for county resources and state of residence. CONCLUSION Women were more likely to experience PCI in the setting of AMI and had less transition to outpatient care during the period. Black patients experienced higher 1-year mortality following PCI, which is explained by differences in baseline comorbidities, county medical resources, and state of residence.
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Affiliation(s)
- Samuel T Savitz
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
- Division of Health Care Delivery Research, Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota, USA
| | - Kristine Falk
- Division of Cardiology, UNC School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Sally C Stearns
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
- Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Lexie R Grove
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Donald E Pathman
- Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
- Department of Family Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Joseph S Rossi
- Division of Cardiology, UNC School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
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Salgado Hernandez JC, Ng SW, Stearns SC, Trogdon JG. Cost-benefit analysis of alternative tax policies on sugar-sweetened beverages in Mexico. PLoS One 2023; 18:e0292276. [PMID: 37788248 PMCID: PMC10547152 DOI: 10.1371/journal.pone.0292276] [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: 03/20/2023] [Accepted: 09/15/2023] [Indexed: 10/05/2023] Open
Abstract
In 2014, Mexico implemented a tax on sugar-sweetened beverages (SSB) equivalent to one Mexican peso (MP) per liter to address the high obesity prevalence. This tax has effectively reduced SSB purchases and yielded healthcare savings; however, it remains unknown whether SSB taxes lead to net benefits at the societal level in Mexico. Moreover, public health experts recommend increasing the tax. The objective of this study is to estimate the net benefits of SSB taxes compared to a scenario of no tax in urban Mexico. Taxes include the one-MP tax and alternative higher taxes (two and three MP per SSB liter). Thus, we conducted a cost-benefit analysis from the perspective of the government, producers, and consumers for a simulated closed cohort of adults in a life-table model. We defined net benefits as the difference between economic benefits (the value of statistical life, healthcare savings, and tax revenue) and costs (consumer surplus and profit losses). We found that, at the societal level, all simulated taxes will eventually generate benefits that surpass costs within ten years. Overall net benefits can reach USD 7.1 billion and 15.3 billion for the one-MP and the three-MP tax, respectively. Hence, these benefits increased at a declining rate compared to taxes. The government and consumers will experience overall positive net benefits among society's members. Policymakers should consider time horizons and tradeoffs between health gains and economic outcomes across different society members.
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Affiliation(s)
- Juan Carlos Salgado Hernandez
- National Institute of Public Health, National Council of Humanities, Science and Technology, Mexico and Center for Research in Nutrition and Health, Cuernavaca, Mexico
| | - Shu Wen Ng
- Carolina Population Center and Department of Nutrition, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States of America
| | - Sally C. Stearns
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States of America
| | - Justin G. Trogdon
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States of America
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Zhu Y, Stearns SC. Hospital safety-net status and postdischarge outcomes: The impact of socioeconomic status and Medicare post-acute care types. J Eval Clin Pract 2023; 29:955-963. [PMID: 36807665 DOI: 10.1111/jep.13815] [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: 12/21/2022] [Revised: 01/19/2023] [Accepted: 01/29/2023] [Indexed: 02/21/2023]
Abstract
AIM To examine the impact of socioeconomic status (SES) and postacute care (PAC) locations on the association between hospital safety-net status and 30-day postdischarge outcomes (readmission, hospice use, or death). METHOD Medicare Current Beneficiary Survey (MCBS) participants during 2006-2011 who were Medicare Fee-for-Service beneficiaries aged 65.5 years or older were included. The associations between hospital safety-net status and 30-day post-discharge outcomes were evaluated by comparing the models with and without PAC and SES adjustments. Safety-net hospital status was defined as being in the top 20% of hospitals ranked by hospital-level percent of total Medicare patient days. SES was measured using individual-level SES (dual eligibility, income, and education) and the Area Deprivation Index (ADI). RESULTS This study identified 13,173 index hospitalizations for 6,825 patients; 1,428 hospitalizations (11.8%) were in safety-net hospitals. The average unadjusted 30-day hospital readmission rate was 22.6% in safety-net hospitals versus 18.8% in nonsafety-net hospitals. Regardless of whether patient SES status was controlled or not, safety-net hospitals had higher estimated probabilities of 30-day readmission (ranging from 0.217 to 0.222 vs. 0.184 to 0.189), and lower probabilities for having neither readmission nor hospice/death (0.750-0.763 vs. 0.780-0.785); for models additionally adjusted for PAC types, safety-net patients had lower rates of hospice use or death (0.019-0.027 vs. 0.030-0.031). CONCLUSIONS The results suggested that safety-net hospitals had lower hospice/death rates but higher readmission rates relative to outcomes at nonsafety-net hospitals. Readmission rate differences were similar regardless of patients' SES status. However, the rate of hospice referral or death rate was related to SES, which suggested that the outcomes were affected by SES and PAC types.
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Affiliation(s)
- Ye Zhu
- Division of Public Health, Infectious Diseases and Occupational Medicine, Mayo Clinic, Rochester, Minnesota, USA
- Department of Health Policy and Management, Gillings School of Global Public Health, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Sally C Stearns
- Department of Health Policy and Management, Gillings School of Global Public Health, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
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Brathwaite D, Strain A, Waller AE, Weinberger M, Stearns SC. The effect of increased emergency department demand on throughput times and disposition status for pediatric psychiatric patients. Am J Emerg Med 2023; 64:174-183. [PMID: 36565662 PMCID: PMC9869182 DOI: 10.1016/j.ajem.2022.11.028] [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: 06/06/2022] [Revised: 10/22/2022] [Accepted: 11/19/2022] [Indexed: 11/27/2022] Open
Abstract
OBJECTIVES Emergency department (ED) crowding has been shown to increase throughput measures of length of stay (LOS), wait time, and boarding time. Psychiatric utilization of the ED has increased, particularly among younger patients. This investigation quantifies the effect of ED demand on throughput times and discharge disposition for pediatric psychiatric patients in the ED. METHODS Using electronic medical record data from 1,151,396 ED visits in eight North Carolina EDs from January 1, 2018, through December 31, 2020, we identified 14,092 pediatric psychiatric visits. Measures of ED daily demand rates included overall occupancy as well as daily proportion of non-psychiatric pediatric patients, adult psychiatric patients, and pediatric psychiatric patients. Controlling for patient-level factors such as age, sex, race, insurance, and triage acuity, we used linear regression to predict throughput times and logistic regression to predict disposition status. We estimated effects of ED demand by academic versus community hospital status due to ED and inpatient resource differences. RESULTS Most ED demand measures had insignificant or only very small associations with throughput measures for pediatric psychiatric patients. Notable exceptions were that a one percentage point increase in the proportion of non-psychiatric pediatric ED visits increased boarding times at community sites by 1.06 hours (95% CI: 0.20-1.92), while a one percentage point increase in the proportion of pediatric psychiatric ED visits increased LOS by 3.64 hours (95% CI: 2.04-5.23) at the academic site. We found that ED demand had a minimal effect on disposition status, with small increases in demand rates favoring <1 percentage point increases in the likelihood of discharge. Instead, patient-level factors played a much stronger role in predicting discharge disposition. CONCLUSIONS ED demand has a meaningful effect on throughput times, but a minimal effect on disposition status. Further research is needed to validate these findings across other state and healthcare systems.
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Affiliation(s)
- Danielle Brathwaite
- University of North Carolina Gillings School of Global Public Health, Department of Health Policy and Management, Chapel Hill, NC, United States of America.
| | - Angela Strain
- University of North Carolina School of Medicine, Department of Emergency Medicine, Chapel Hill, NC, United States of America.
| | - Anna E Waller
- University of North Carolina School of Medicine, Department of Emergency Medicine & Carolina Center for Health Informatics, Chapel Hill, NC, United States of America.
| | - Morris Weinberger
- University of North Carolina Gillings School of Global Public Health, Department of Health Policy and Management, Chapel Hill, NC, United States of America.
| | - Sally C Stearns
- University of North Carolina Gillings School of Global Public Health, Department of Health Policy and Management, Chapel Hill, NC, United States of America.
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6
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Miller KEM, Van Houtven CH, Kent EE, Gilleskie D, Holmes GM, Smith VA, Stearns SC. Short-term effects of comprehensive caregiver supports on caregiver outcomes. Health Serv Res 2023; 58:140-153. [PMID: 35848763 PMCID: PMC10501334 DOI: 10.1111/1475-6773.14038] [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] [Indexed: 01/17/2023] Open
Abstract
OBJECTIVE To estimate the association of the Veterans Health Administration (VHA) Program of Comprehensive Assistance for Family Caregivers (PCAFC) implemented in 2011 with caregiver health and health care use. DATA SOURCES VHA claims and electronic health records from May 2009 to May 2018. STUDY DESIGN Using a retrospective, pre-post study design with inverse probability of treatment weights to address selection into treatment, we examine the association of PCAFC on caregivers who are veterans: (1) outpatient primary, specialty, and mental health care visits; (2) probability of uncontrolled hypertension and anxiety/depression; and (3) VHA health care costs. We compare outcomes for caregivers approved for PCAFC (treatment) to caregivers denied PCAFC (comparison). DATA COLLECTION/EXTRACTION METHODS Not applicable. PRINCIPAL FINDINGS In the year pre-application, we observe similar probabilities of having any VHA primary care (~36%), VHA specialty care (~24%), and VHA or VHA-purchased mental health care (~22%) for treatment and comparison caregivers. In the year post-application, treated caregivers had a 5.89 percentage point larger probability of any outpatient VHA primary care (p = 0.002) and 4.34 percentage points larger probability of any outpatient mental health care use (p = 0.014). Post-application, probabilities of having uncontrolled hypertension or diagnosed anxiety/depression were higher for both treated and comparison groups. In the second year post-application, treated caregivers had a 1.88 percentage point larger probability of uncontrolled hypertension (p = 0.019) and 4.68 percentage points larger probability of diagnosed anxiety/depression (predicted probabilities: treated = 0.30; comparison = 0.25; p = 0.005). We find no evidence of differences in VHA total costs by PCAFC status. CONCLUSIONS Our findings that PCAFC enrollment is associated with increased health care diagnosis and service use may reflect improved access for previously unmet needs in the population of veteran caregivers for veterans in PCAFC. The costs and value of these increases can be weighed against other effects of the program to inform national policies supporting caregivers.
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Affiliation(s)
- Katherine E. M. Miller
- Durham Center of Innovation to Accelerate Discovery and Practice TransformationDurham Virginia Health Care SystemDurhamNorth CarolinaUSA
- Department of Health Policy and Management, Gillings School of Global Public HealthThe University of North Carolina at Chapel HillChapel HillNorth CarolinaUSA
| | - Courtney H. Van Houtven
- Durham Center of Innovation to Accelerate Discovery and Practice TransformationDurham Virginia Health Care SystemDurhamNorth CarolinaUSA
- Department of Population Health SciencesDuke UniversityDurhamNorth CarolinaUSA
- Duke Margolis Center for Health PolicyDuke UniversityDurhamNorth CarolinaUSA
| | - Erin E. Kent
- Department of Health Policy and Management, Gillings School of Global Public HealthThe University of North Carolina at Chapel HillChapel HillNorth CarolinaUSA
- Lineberger Comprehensive Cancer CenterThe University of North Carolina at Chapel HillChapel HillNorth CarolinaUSA
- Cecil G. Sheps Center for Health Services ResearchThe University of North Carolina at Chapel HillChapel HillNorth CarolinaUSA
| | - Donna Gilleskie
- Department of EconomicsThe University of North Carolina at Chapel HillChapel HillNorth CarolinaUSA
| | - G. Mark Holmes
- Department of Health Policy and Management, Gillings School of Global Public HealthThe University of North Carolina at Chapel HillChapel HillNorth CarolinaUSA
- Cecil G. Sheps Center for Health Services ResearchThe University of North Carolina at Chapel HillChapel HillNorth CarolinaUSA
| | - Valerie A. Smith
- Durham Center of Innovation to Accelerate Discovery and Practice TransformationDurham Virginia Health Care SystemDurhamNorth CarolinaUSA
- Department of Population Health SciencesDuke UniversityDurhamNorth CarolinaUSA
- Division of General Internal Medicine, Department of MedicineDuke UniversityDurhamNorth CarolinaUSA
| | - Sally C. Stearns
- Department of Health Policy and Management, Gillings School of Global Public HealthThe University of North Carolina at Chapel HillChapel HillNorth CarolinaUSA
- Cecil G. Sheps Center for Health Services ResearchThe University of North Carolina at Chapel HillChapel HillNorth CarolinaUSA
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7
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Shafer PR, Dusetzina SB, Sabik LM, Platts-Mills TF, Stearns SC, Trogdon JG. High Deductible Health Plans and Use of Free Preventive Services Under the Affordable Care Act. Inquiry 2023; 60:469580231182512. [PMID: 37329296 DOI: 10.1177/00469580231182512] [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] [Subscribe] [Scholar Register] [Indexed: 06/19/2023]
Abstract
The Affordable Care Act aimed to increase use of preventive services by eliminating cost-sharing to consumers. However, patients may be unaware of this benefit or they may not seek preventive services if they anticipate that the cost of potential diagnostic or treatment services will be too high, both more likely among those in high deductible health plans. We used nationally representative private health insurance claims (100% sample of IBM® MarketScan®) for the United States from 2006 to 2018, restricting the data to enrollment and claims for non-elderly adults who were enrolled for the full plan year. The cross-sectional sample (185 million person-years) is used to describe trends in preventive service use and costs from 2008 through 2016. The cohort sample (9 million people) focuses on the elimination of cost-sharing for certain high-value preventive services in late 2010, requiring continuous enrollment across 2010 and 2011. We examine whether HDHP enrollment is associated with use of eligible preventive services using semi-parametric difference-in-differences to account for endogenous plan selection. Our preferred model implies that HDHP enrollment was associated with a reduction of the post-ACA change in any use of eligible preventive services by 0.2 percentage points or 12.5%. Cancer screenings were unaffected but HDHP enrollment was associated with smaller increases in wellness visits, immunizations, and screening for chronic conditions and sexually transmitted infections. We also find that the policy was ineffective at reducing out-of-pocket costs for the eligible preventive services, likely due to implementation issues.
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Affiliation(s)
- Paul R Shafer
- Department of Health Law, Policy, and Management, School of Public Health, Boston University, Boston, MA, USA
| | | | - Lindsay M Sabik
- School of Public Health, University of Pittsburgh, Pittsburgh, PA, USA
| | | | - Sally C Stearns
- Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Justin G Trogdon
- Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
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8
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Zhu Y, Stearns SC, Holmes GM. The contributions of survey-based versus administrative measures of socioeconomic status in predicting type of post-acute care for hospitalized Medicare beneficiaries. J Eval Clin Pract 2022; 28:569-580. [PMID: 34940987 DOI: 10.1111/jep.13647] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2021] [Revised: 12/01/2021] [Accepted: 12/08/2021] [Indexed: 11/27/2022]
Abstract
OBJECTIVES To assess and compare the associations between socioeconomic status (SES) measures from two sources (claims vs. survey data) and the type of post-acute care (PAC) locations following hospital discharge. METHODS This observational study included Medicare Fee-for-Service (FFS) beneficiaries age 65.5 years or older who participated in the Medicare Current Beneficiary Survey (MCBS) and were hospitalized in 2006-2011. Multiple data sets were used including: Area Deprivation Index; Medicare Cost Reports, Provider of Services files, and Area Health Resource File. Multinomial regression models estimated associations between beneficiary's SES and PAC type. SES measures came from surveys (income and education) and administrative records (dual enrollment and area deprivation). PAC types included home with self-care, home health agency, skilled nursing facility (SNF), or inpatient rehabilitation facility. RESULTS Low income and dual enrollment were associated with higher SNF use while living in a deprived area was associated with lower SNF use and higher use of home with self-care. Dual enrollment and area deprivation were associated with the largest differences. CONCLUSIONS If policies to modify payment based on SES are considered, administrative measures (dual enrollment and area deprivation) rather than survey measures (education and income) may be sufficient.
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Affiliation(s)
- Ye Zhu
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota, USA.,Division of Health Care Policy and Research, Department of Health Sciences Research, Mayo Clinic, Rochester, Minnesota, USA.,Department of Health Policy and Management, The University of North Carolina at Chapel Hill, Gillings School of Global Public Health, Chapel Hill, North Carolina, USA
| | - Sally C Stearns
- Department of Health Policy and Management, The University of North Carolina at Chapel Hill, Gillings School of Global Public Health, Chapel Hill, North Carolina, USA
| | - George M Holmes
- Department of Health Policy and Management, The University of North Carolina at Chapel Hill, Gillings School of Global Public Health, Chapel Hill, North Carolina, USA
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Hurka-Richardson K, Platts-Mills TF, McLean SA, Weinberger M, Stearns SC, Bush M, Quackenbush E, Chari S, Aylward A, Kroenke K, Kerns RD, Weaver MA, Keefe FJ, Berkoff D, Meyer ML. Brief Educational Video plus Telecare to Enhance Recovery for Older Emergency Department Patients with Acute Musculoskeletal Pain: an update to the study protocol for a randomized controlled trial. Trials 2022; 23:400. [PMID: 35550175 PMCID: PMC9096747 DOI: 10.1186/s13063-022-06310-z] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2022] [Accepted: 03/22/2022] [Indexed: 11/16/2022] Open
Abstract
Background This update describes changes to the Brief Educational Tool to Enhance Recovery (BETTER) trial in response to the COVID-19 pandemic. Methods/design The original protocol was published in Trials. Due to the COVID-19 pandemic, the BETTER trial converted to remote recruitment in April 2020. All recruitment, consent, enrollment, and randomization now occur by phone within 24 h of the acute care visit. Other changes to the original protocol include an expansion of inclusion criteria and addition of new recruitment sites. To increase recruitment numbers, eligibility criteria were expanded to include individuals with chronic pain, non-daily opioid use within 2 weeks of enrollment, presenting musculoskeletal pain (MSP) symptoms for more than 1 week, hospitalization in past 30 days, and not the first time seeking medical treatment for presenting MSP pain. In addition, recruitment sites were expanded to other emergency departments and an orthopedic urgent care clinic. Conclusions Recruiting from an orthopedic urgent care clinic and transitioning to remote operations not only allowed for continued participant enrollment during the pandemic but also resulted in some favorable outcomes, including operational efficiencies, increased enrollment, and broader generalizability. Trial registration ClinicalTrials.gov NCT04118595. Registered on October 8, 2019.
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Affiliation(s)
- Karen Hurka-Richardson
- Department of Emergency Medicine, University of North Carolina at Chapel Hill, Houpt Bldg, 170 Manning Dr, Chapel Hill, NC, USA
| | | | - Samuel A McLean
- Department of Emergency Medicine, University of North Carolina at Chapel Hill, Houpt Bldg, 170 Manning Dr, Chapel Hill, NC, USA.,Department of Anesthesiology, University of North Carolina Hospitals, Chapel Hill, NC, USA
| | - Morris Weinberger
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Sally C Stearns
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Montika Bush
- Department of Emergency Medicine, University of North Carolina at Chapel Hill, Houpt Bldg, 170 Manning Dr, Chapel Hill, NC, USA
| | - Eugenia Quackenbush
- Department of Emergency Medicine, University of North Carolina at Chapel Hill, Houpt Bldg, 170 Manning Dr, Chapel Hill, NC, USA
| | - Srihari Chari
- Department of Emergency Medicine, University of North Carolina at Chapel Hill, Houpt Bldg, 170 Manning Dr, Chapel Hill, NC, USA
| | - Aileen Aylward
- Department of Emergency Medicine, University of North Carolina at Chapel Hill, Houpt Bldg, 170 Manning Dr, Chapel Hill, NC, USA
| | - Kurt Kroenke
- Regenstrief Institute and Department of Medicine, Indiana University, Indianapolis, IN, USA
| | - Robert D Kerns
- Departments of Psychiatry, Neurology and Psychology, Yale University, New Haven, CT, USA
| | - Mark A Weaver
- Department of Mathematics and Statistics, Elon University, Elon, NC, USA
| | - Francis J Keefe
- Department of Psychology and Neuroscience, Duke University, Durham, NC, USA
| | - David Berkoff
- Department of Orthopedics, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Michelle L Meyer
- Department of Emergency Medicine, University of North Carolina at Chapel Hill, Houpt Bldg, 170 Manning Dr, Chapel Hill, NC, USA.
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Savitz ST, Falk K, Stearns SC, Grove L, Rossi J. Coronary revascularization outcomes in relation to skilled nursing facility use following hospital discharge. Clin Cardiol 2021; 44:627-635. [PMID: 33755210 PMCID: PMC8119835 DOI: 10.1002/clc.23583] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [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: 11/10/2020] [Revised: 02/08/2021] [Accepted: 02/18/2021] [Indexed: 01/09/2023] Open
Abstract
Background Observational analyses comparing coronary artery bypass surgery (CABG) and percutaneous coronary intervention (PCI) among elderly or frail patients are likely biased by treatment selection. PCI is typically chosen for frail patients, while CABG is more common for patients with good recovery potential. Hypothesis We hypothesized that skilled nursing facility (SNF) use after revascularization is a measure of relative frailty associated with outcomes following coronary revascularization. Methods We used a 20 percent sample of Medicare beneficiaries aged 65 years or older who received inpatient PCI or CABG between 2007–2014. Key explanatory variables were the revascularization strategy and SNF use after revascularization. We used Cox regression to evaluate death and repeat revascularization within one year and logistic regression to evaluate SNF use and 30‐day readmissions/death. Results CABG patients were 25.1 percentage points [95% confidence interval: 24.7, 25.5] more likely to use SNF following revascularization than inpatient PCI patients. SNF use was associated with a higher death rate (hazard ratio (HR): 3.19 [3.02, 3.37]) and a 16.2 percentage point (15.5, 16.9) increase in 30‐day readmissions/death. Among patients with SNF use, CABG was associated with a decrease in 30‐day readmissions/death compared to PCI. Conclusions While CABG was associated with higher rates of SNF use and 30‐day readmission/death overall, CABG was associated with significantly lower rates of 30‐day readmissions/death among patients with SNF use. The findings suggest that caution is needed in treatment selection for patients at high‐risk for SNF use and that selection of inpatient PCI over CABG may be associated with frailty and worse outcomes for some patients.
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Affiliation(s)
- Samuel T. Savitz
- Robert D. and Patricia E. Kern Center for the Science of Health Care DeliveryMayo ClinicRochesterMinnesotaUSA
- Division of Health Care Delivery ResearchMayo ClinicRochesterMinnesotaUSA
- Division of ResearchKaiser Permanente Northern CaliforniaOaklandCaliforniaUSA
- Department of Health Policy and Management, Gillings School of Global Public HealthThe University of North Carolina at Chapel HillChapel HillNorth CarolinaUSA
| | - Kristine Falk
- Division of Cardiology, UNC School of MedicineThe University of North Carolina at Chapel HillChapel HillNorth CarolinaUSA
| | - Sally C. Stearns
- Department of Health Policy and Management, Gillings School of Global Public HealthThe University of North Carolina at Chapel HillChapel HillNorth CarolinaUSA
- Cecil G. Sheps Center for Health Services ResearchThe University of North Carolina at Chapel HillChapel HillNorth CarolinaUSA
| | - Lexie Grove
- Department of Health Policy and Management, Gillings School of Global Public HealthThe University of North Carolina at Chapel HillChapel HillNorth CarolinaUSA
- Cecil G. Sheps Center for Health Services ResearchThe University of North Carolina at Chapel HillChapel HillNorth CarolinaUSA
| | - Joseph Rossi
- Division of Cardiology, UNC School of MedicineThe University of North Carolina at Chapel HillChapel HillNorth CarolinaUSA
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11
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LeCraw FR, Stearns SC, McCoy MJ. How U.S. teams advanced communication and resolution program adoption at local, state and national levels. Journal of Patient Safety and Risk Management 2020. [DOI: 10.1177/2516043520973818] [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: 11/17/2022]
Abstract
Widespread adoption of evidence-based new healthcare practice guidelines can take years to occur. Policy leaders frequently make decisions based on incomplete and often incorrect information. These policy decisions can result in wasteful healthcare spending and poor health outcomes. Proponents of a medicolegal policy, Communication-and-Resolution Program (CRP), were successful in their endeavor to get hospitals to implement CRP, state legislators to pass state laws to encourage CRP adoption by hospitals, and national medical societies to endorse CRP to their members. The purpose of this paper is to explain the methods used by nine teams in their efforts to accomplish these goals. We identify reasons for the successes, failures, and obstacles faced by the teams in their effort to advance CRP. Our hope is to educate groups on a potentially more expeditious method to advance evidence-based policy than other methods. We propose that advocates of an innovation determine the concerns and goals of all stakeholder groups impacted by the policy. The specific concerns of each group should be the focus of the message to that group. Teams should identify the opinion leaders of each stakeholder group who can champion the new policy to their peers. Teams can aid the opinion leaders in their communication efforts to their peer group. National groups should be organized to help teams in their endeavor to advance evidence-based policies.
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Affiliation(s)
- Florence R LeCraw
- Andrew Young School of Policy Studies, Georgia State University, Atlanta, GA, USA
| | - Sally C Stearns
- Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Michael J McCoy
- Department of Administration, Great River Health System, West Burlington, IA, USA
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12
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Savitz ST, Bailey SC, Dusetzina SB, Jones WS, Trogdon JG, Stearns SC. Treatment selection and medication adherence for stable angina: The role of area-based health literacy. J Eval Clin Pract 2020; 26:1711-1721. [PMID: 31994280 PMCID: PMC7552995 DOI: 10.1111/jep.13341] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [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] [Received: 09/26/2019] [Revised: 11/28/2019] [Accepted: 11/29/2019] [Indexed: 01/09/2023]
Abstract
RATIONALE, AIMS, AND OBJECTIVES Clinical studies show equivalent health outcomes from interventional procedures and treatment with medication only for stable angina patients. However, patients may be subject to overuse or access barriers for interventional procedures and may exhibit suboptimal adherence to medications. Our objective is to evaluate whether community-level health literacy is associated with treatment selection and medication adherence patterns. METHOD The sample included Medicare fee-for-service beneficiaries (20% random sample) with stable angina in 2007-2013. We used an area-level health literacy variable because of the lack of an individual measure in claims. We measured the association between (a) area-based health literacy with treatment selection (medication only, percutaneous coronary intervention [PCI], or coronary artery bypass grafting (CABG) surgery) and (b) area-based health literacy with medication adherence. We controlled for other factors including demographics, co-morbidity burden, dual eligibility, and area deprivation index. RESULTS We identified 8300 patients of whom 8.7% lived in a low health literacy area. Overall, 56% of patients received medication only, 28% received PCI, and 15% received CABG. Patients in low health literacy areas were less likely to receive CABG (-3.5 percentage points; 95% CI, -6.8 to -0.3) than were patients in high health literacy areas, but the significance was sensitive to specification. Overall, 81.5% and 71.5% of patients were adherent to antianginals and statins, respectively. Living in low health literacy areas was associated with lower adherence to antianginals (-3.3 percentage points; 95% CI, -6.1 to -0.6) but not statins. CONCLUSIONS Low area-based health literacy was associated with being less likely to receive CABG and lower adherence, but the differences between low and high health literacy areas were small and sensitive to model specification. Individual factors such as dual eligibility status and race/ethnicity had stronger associations with outcomes than had area-based health literacy, suggesting that this area-based measure was inadequate to account for social determinants in this study.
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Affiliation(s)
- Samuel T Savitz
- Department of Health Policy & Management, Gillings School of Global Public Health, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina.,Cecil G. Sheps Center for Health Services Research, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Stacy Cooper Bailey
- Division of General Internal Medicine and Geriatrics, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Stacie B Dusetzina
- Department of Health Policy, Vanderbilt University Medical Center, Nashville, Tennessee
| | - W Schuyler Jones
- Department of Medicine, Duke Heart Center, Duke University Medical Center, Durham, North Carolina
| | - Justin G Trogdon
- Department of Health Policy & Management, Gillings School of Global Public Health, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Sally C Stearns
- Department of Health Policy & Management, Gillings School of Global Public Health, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina.,Cecil G. Sheps Center for Health Services Research, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
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13
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Shafer PR, Dusetzina SB, Sabik LM, Platts-Mills TF, Stearns SC, Trogdon JG. Insurance instability and use of emergency and office-based care after gaining coverage: An observational cohort study. PLoS One 2020; 15:e0238100. [PMID: 32886675 PMCID: PMC7473517 DOI: 10.1371/journal.pone.0238100] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [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] [Subscribe] [Scholar Register] [Received: 04/02/2020] [Accepted: 08/10/2020] [Indexed: 11/21/2022] Open
Abstract
Background The Affordable Care Act led to improvements in reporting a usual source of care, but it is unclear whether patients are changing their usual source of care in response to coverage gains. We assess whether prior insurance instability is associated with changes in use of emergency and office-based care after the Marketplace and Medicaid expansion were introduced. Methods Our study draws from the 2013–14 Medical Expenditure Panel Survey, identifying a cohort of non-elderly adults with full-year health insurance coverage in 2014. We use linear and multinomial logistic regression to assess the relationship between insurance instability prior to 2014 (uninsured for 1–11 months, ≥12 months) and person-level changes in use of health care after gaining coverage (change in ED and office visits from 2013 to 2014) with continuously insured individuals serving as a comparison group. Results Being uninsured for at least one year prior to gaining full-year coverage in 2014 was associated with a 33% increase in ED visits (0.06 visits, p<0.01) and a 47% increase in office visits (1.10 visits, p<0.01), driven by those gaining public coverage. We found no evidence of substitution across settings in the short term, often a stated goal of expansion. Conclusion The long-term uninsured may have substantial health needs and pent-up demand for health care, seeing more physicians across multiple settings in the year after gaining coverage as they seek to get unmanaged conditions under control. Closing the gap in primary care use between the previously uninsured and those with health insurance coverage may help improve long-term health outcomes.
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Affiliation(s)
- Paul R. Shafer
- Department of Health Law, Policy, and Management, School of Public Health, Boston University, Boston, Massachusetts, United States of America
- * E-mail:
| | - Stacie B. Dusetzina
- Department of Health Policy, School of Medicine, Vanderbilt University, Nashville, Tennessee, United States of America
| | - Lindsay M. Sabik
- Department of Health Policy and Management, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, Pennsylvania, United States of America
| | - Timothy F. Platts-Mills
- Department of Emergency Medicine, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States of America
| | - Sally C. Stearns
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States of America
| | - Justin G. Trogdon
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States of America
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14
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Garcia Reeves AB, Trogdon JG, Stearns SC, Lewis JW, Weber DJ, Weinberger M. Are Rates of Methicillin-Resistant Staphylococcus aureus and Clostridioides difficile Associated With Quality and Clinical Outcomes in US Acute Care Hospitals? Am J Med Qual 2020; 36:90-98. [PMID: 32686484 DOI: 10.1177/1062860620942310] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The purpose of this study was to examine the association between rates of methicillin-resistant Staphylococcus aureus (MRSA)/Clostridioides difficile and quality and clinical outcomes in US acute care hospitals. The population was all Medicare-certified US acute care hospitals with MRSA/C difficile standardized infection ratio (SIR) data available from 2013 to 2017. Hospital-level data from the Centers for Medicare & Medicaid Services were used to estimate hospital and time fixed effects models for 30-day hospital readmissions, length of stay, 30-day mortality, and days in the intensive care unit. The key explanatory variables were SIR for MRSA and C difficile. No association was found between MRSA or C difficile rates and any of the 4 outcomes. The null results add to the mixed evidence in the field, but there are likely residual confounding factors. Future research should use larger samples of patient-level data and appropriate methods to provide evidence to guide efforts to tackle antimicrobial resistance.
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Affiliation(s)
- Alessandra B Garcia Reeves
- University of North Carolina, Chapel Hill, NC North Carolina Department of Health and Human Services, Raleigh, NC
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15
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Platts-Mills TF, McLean SA, Weinberger M, Stearns SC, Bush M, Teresi BB, Hurka-Richardson K, Kroenke K, Kerns RD, Weaver MA, Keefe FJ. Brief educational video plus telecare to enhance recovery for older emergency department patients with acute musculoskeletal pain: study protocol for the BETTER randomized controlled trial. Trials 2020; 21:615. [PMID: 32631400 PMCID: PMC7336469 DOI: 10.1186/s13063-020-04552-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [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] [Subscribe] [Scholar Register] [Received: 05/01/2020] [Accepted: 06/23/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Chronic musculoskeletal pain (MSP) affects more than 40% of adults aged 50 years and older and is the leading cause of disability in the USA. Older adults with chronic MSP are at risk for analgesic-related side effects, long-term opioid use, and functional decline. Recognizing the burden of chronic MSP, reducing the transition from acute to chronic pain is a public health priority. In this paper, we report the protocol for the Brief EducaTional Tool to Enhance Recovery (BETTER) trial. This trial compares two versions of an intervention to usual care for preventing the transition from acute to chronic MSP among older adults in the emergency department (ED). METHODS Three hundred sixty patients from the ED will be randomized to one of three arms: full intervention (an interactive educational video about pain medications and recovery-promoting behaviors, a telecare phone call from a nurse 48 to 72 h after discharge from the ED, and an electronic communication containing clinical information to the patient's primary care provider); video-only intervention (the interactive educational video but no telecare or primary care provider communication); or usual care. Data collection will occur at baseline and at 1 week and 1, 3, 6, and 12 months after study enrollment. The primary outcome is a composite measure of pain severity and interference. Secondary outcomes include physical function, overall health, opioid use, healthcare utilization, and an assessment of the economic value of the intervention. DISCUSSION This trial is the first patient-facing ED-based intervention aimed at helping older adults to better manage their MSP and reduce their risk of developing chronic pain. If effective, future studies will examine the effectiveness of implementation strategies. TRIAL REGISTRATION ClinicalTrials.gov NCT04118595 . Registered on 8 October 2019.
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Affiliation(s)
- Timothy F. Platts-Mills
- Department of Emergency Medicine, University of North Carolina at Chapel Hill, Houpt Bldg, 170 Manning Dr, Chapel Hill, NC 27599 USA
| | - Samuel A. McLean
- Department of Anesthesiology, University of North Carolina Hospitals, Chapel Hill, NC USA
| | - Morris Weinberger
- Department of Health Policy and Management, Gillings School of Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC USA
| | - Sally C. Stearns
- Department of Health Policy and Management, Gillings School of Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC USA
| | - Montika Bush
- Department of Emergency Medicine, University of North Carolina at Chapel Hill, Houpt Bldg, 170 Manning Dr, Chapel Hill, NC 27599 USA
| | - Brittni B. Teresi
- Department of Emergency Medicine, University of North Carolina at Chapel Hill, Houpt Bldg, 170 Manning Dr, Chapel Hill, NC 27599 USA
| | - Karen Hurka-Richardson
- Department of Emergency Medicine, University of North Carolina at Chapel Hill, Houpt Bldg, 170 Manning Dr, Chapel Hill, NC 27599 USA
| | - Kurt Kroenke
- Regenstrief Institute and Department of Medicine, Indiana University, Indianapolis, IN USA
| | | | - Mark A. Weaver
- Department of Mathematics and Statistics, Elon University, Elon, NC USA
| | - Francis J. Keefe
- Department of Psychology and Neuroscience, Duke University, Durham, NC USA
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16
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Zimmerman S, Sloane PD, Ward K, Wretman CJ, Stearns SC, Poole P, Preisser JS. Effectiveness of a Mouth Care Program Provided by Nursing Home Staff vs Standard Care on Reducing Pneumonia Incidence: A Cluster Randomized Trial. JAMA Netw Open 2020; 3:e204321. [PMID: 32558913 PMCID: PMC7305523 DOI: 10.1001/jamanetworkopen.2020.4321] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2019] [Accepted: 03/01/2020] [Indexed: 12/30/2022] Open
Abstract
Importance Pneumonia affects more than 250 000 nursing home (NH) residents annually. A strategy to reduce pneumonia is to provide daily mouth care, especially to residents with dementia. Objective To evaluate the effectiveness of Mouth Care Without a Battle, a program that increases staff knowledge and attitudes regarding oral hygiene, changes mouth care, and improves oral hygiene, in reducing the incidence of pneumonia among NH residents. Design, Setting, and Participants This pragmatic cluster randomized trial observing 2152 NH residents for up to 2 years was conducted from September 2014 to May 2017. Data collectors were masked to study group. The study included 14 NHs from regions of North Carolina that evidenced proportionately high rehospitalization rates for pneumonia and long-term care residents. Nursing homes were pair matched and randomly assigned to intervention or control groups. Intervention Mouth Care Without a Battle is a standardized program that teaches that mouth care is health care, provides instruction on individualized techniques and products for mouth care, and trains caregivers to provide care to residents who are resistant and in special situations. The control condition was standard mouth care. Main Outcomes and Measures Pneumonia incidence (primary) and hospitalization and mortality (secondary), obtained from medical records. Results Overall, the study enrolled 2152 residents (mean [SD] age, 79.4 [12.4] years; 1281 [66.2%] women; 1180 [62.2%] white residents). Participants included 1219 residents (56.6%) in 7 intervention NHs and 933 residents (43.4%) in 7 control NHs. During the 2-year study period, the incidence rate of pneumonia per 1000 resident-days was 0.67 and 0.72 in the intervention and control NHs, respectively. Neither the primary (unadjusted) nor secondary (covariate-adjusted) analyses found a significant reduction in pneumonia due to Mouth Care Without a Battle during 2 years (unadjusted incidence rate ratio, 0.90; upper bound of 1-sided 95% CI, 1.24; P = .27; adjusted incidence rate ratio, 0.92; upper bound of 1-sided 95% CI, 1.27; P = .30). In the second year, the rate of pneumonia was nonsignificantly higher in intervention NHs. Adjusted post hoc analyses limited to the first year found a significant reduction in pneumonia incidence in intervention NHs (IRR, 0.69; upper bound of 1-sided 95% CI, 0.94; P = .03). Conclusions and Relevance This matched-pairs cluster randomized trial of a mouth care program compared with standard care was not effective in reducing pneumonia incidence at 2 years, although reduction was found during the first year. The lack of significant results in the second year may be associated with sustainability. Improving mouth care in US NHs may require the presence and support of dedicated oral care aides. Trial Registration ClinicalTrials.gov Identifier: NCT03817450.
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Affiliation(s)
- Sheryl Zimmerman
- The Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill
- School of Social Work, University of North Carolina at Chapel Hill
- Gillings School of Global Public Health, University of North Carolina at Chapel Hill
| | - Philip D. Sloane
- The Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill
- Department of Family Medicine, School of Medicine, University of North Carolina at Chapel Hill
| | - Kimberly Ward
- The Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill
| | - Christopher J. Wretman
- The Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill
- School of Social Work, University of North Carolina at Chapel Hill
| | - Sally C. Stearns
- Gillings School of Global Public Health, University of North Carolina at Chapel Hill
| | - Patricia Poole
- The Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill
| | - John S. Preisser
- Gillings School of Global Public Health, University of North Carolina at Chapel Hill
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17
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Zhu Y, Stearns SC. Post‐Acute Care Locations: Hospital Discharge Destination Reports vs Medicare Claims. J Am Geriatr Soc 2019; 68:847-851. [DOI: 10.1111/jgs.16308] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2019] [Revised: 11/18/2019] [Accepted: 12/02/2019] [Indexed: 11/27/2022]
Affiliation(s)
- Ye Zhu
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery Mayo Clinic Rochester Minnesota
- Division of Health Care Policy and Research, Department of Health Sciences Research Mayo Clinic Rochester Minnesota
| | - Sally C. Stearns
- Department of Health Policy and Management The University of North Carolina at Chapel Hill, Gillings School of Global Public Health Chapel Hill North Carolina
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18
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Savitz ST, Dobler CC, Shah ND, Bennett AV, Bailey SC, Dusetzina SB, Jones WS, Stearns SC, Montori VM. Patient-Clinician Decision Making for Stable Angina: The Role of Health Literacy. EGEMS (Wash DC) 2019; 7:42. [PMID: 31406699 PMCID: PMC6688543 DOI: 10.5334/egems.306] [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] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/08/2018] [Accepted: 07/10/2019] [Indexed: 11/20/2022]
Abstract
BACKGROUND Stable angina patients have difficulty understanding the tradeoffs between treatment alternatives. In this analysis, we assessed treatment planning conversations for stable angina to determine whether inadequate health literacy acts as a barrier to communication that may partially explain this difficulty. METHODS We conducted a descriptive analysis of patient questionnaire data from the PCI Choice Trial. The main outcomes were the responses to the Decisional Conflict Scale and the proportion of correct responses to knowledge questions about stable angina. We also conducted a qualitative analysis on recordings of patient-clinician discussions about treatment planning. The recordings were coded with the OPTION12 instrument for shared decision-making. Two analysts independently assessed the number and types of patient questions and expressions of preferences. RESULTS Patient engagement did not differ by health literacy level and was generally low for all patients with respect to OPTION12 scores and the number of questions related to clinical aspects of treatment. Patients with inadequate health literacy had significantly higher decisional conflict. However, the proportion of knowledge questions answered correctly did not differ significantly by health literacy level. CONCLUSIONS Patients with inadequate health literacy had greater decisional conflict but no difference in knowledge compared to patients with adequate health literacy. Inadequate health literacy may act as a barrier to communication, but gaps were found in patient engagement and knowledge for patients of all health literacy levels. The recorded patient-clinician encounters and the health literacy measure were valuable resources for conducting research on care delivery.
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Gehi AK, Deyo Z, Mendys P, Hatfield L, Laux J, Walker TJ, Chen S, O'Bryan J, Garner K, Sears SF, Akiyama J, Stearns SC, Biese K. Novel Care Pathway for Patients Presenting to the Emergency Department With Atrial Fibrillation. Circ Cardiovasc Qual Outcomes 2019; 11:e004129. [PMID: 29330141 DOI: 10.1161/circoutcomes.117.004129] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Anil K Gehi
- From the Division of Cardiology, Department of Medicine (A.G., P.M., T.J.W., S.C., J.O., K.G.), University of North Carolina Medical Center (Z.D., L.H.), Division of Practice Advancement and Clinical Education, University of North Carolina Eshelman School of Pharmacy (Z.D., P.M., L.H.), Gillings School of Global Public Health (J.L., J.A., S.S.), and Department of Emergency Medicine (K.B.), University of North Carolina at Chapel Hill; and Department of Psychology (S.S.), Department of Cardiovascular Sciences (S.S.), and Department of Public Health (S.S.), East Carolina University, Greenville, NC.
| | - Zachariah Deyo
- From the Division of Cardiology, Department of Medicine (A.G., P.M., T.J.W., S.C., J.O., K.G.), University of North Carolina Medical Center (Z.D., L.H.), Division of Practice Advancement and Clinical Education, University of North Carolina Eshelman School of Pharmacy (Z.D., P.M., L.H.), Gillings School of Global Public Health (J.L., J.A., S.S.), and Department of Emergency Medicine (K.B.), University of North Carolina at Chapel Hill; and Department of Psychology (S.S.), Department of Cardiovascular Sciences (S.S.), and Department of Public Health (S.S.), East Carolina University, Greenville, NC
| | - Philip Mendys
- From the Division of Cardiology, Department of Medicine (A.G., P.M., T.J.W., S.C., J.O., K.G.), University of North Carolina Medical Center (Z.D., L.H.), Division of Practice Advancement and Clinical Education, University of North Carolina Eshelman School of Pharmacy (Z.D., P.M., L.H.), Gillings School of Global Public Health (J.L., J.A., S.S.), and Department of Emergency Medicine (K.B.), University of North Carolina at Chapel Hill; and Department of Psychology (S.S.), Department of Cardiovascular Sciences (S.S.), and Department of Public Health (S.S.), East Carolina University, Greenville, NC
| | - Leah Hatfield
- From the Division of Cardiology, Department of Medicine (A.G., P.M., T.J.W., S.C., J.O., K.G.), University of North Carolina Medical Center (Z.D., L.H.), Division of Practice Advancement and Clinical Education, University of North Carolina Eshelman School of Pharmacy (Z.D., P.M., L.H.), Gillings School of Global Public Health (J.L., J.A., S.S.), and Department of Emergency Medicine (K.B.), University of North Carolina at Chapel Hill; and Department of Psychology (S.S.), Department of Cardiovascular Sciences (S.S.), and Department of Public Health (S.S.), East Carolina University, Greenville, NC
| | - Jeffrey Laux
- From the Division of Cardiology, Department of Medicine (A.G., P.M., T.J.W., S.C., J.O., K.G.), University of North Carolina Medical Center (Z.D., L.H.), Division of Practice Advancement and Clinical Education, University of North Carolina Eshelman School of Pharmacy (Z.D., P.M., L.H.), Gillings School of Global Public Health (J.L., J.A., S.S.), and Department of Emergency Medicine (K.B.), University of North Carolina at Chapel Hill; and Department of Psychology (S.S.), Department of Cardiovascular Sciences (S.S.), and Department of Public Health (S.S.), East Carolina University, Greenville, NC
| | - T Jennifer Walker
- From the Division of Cardiology, Department of Medicine (A.G., P.M., T.J.W., S.C., J.O., K.G.), University of North Carolina Medical Center (Z.D., L.H.), Division of Practice Advancement and Clinical Education, University of North Carolina Eshelman School of Pharmacy (Z.D., P.M., L.H.), Gillings School of Global Public Health (J.L., J.A., S.S.), and Department of Emergency Medicine (K.B.), University of North Carolina at Chapel Hill; and Department of Psychology (S.S.), Department of Cardiovascular Sciences (S.S.), and Department of Public Health (S.S.), East Carolina University, Greenville, NC
| | - Sarah Chen
- From the Division of Cardiology, Department of Medicine (A.G., P.M., T.J.W., S.C., J.O., K.G.), University of North Carolina Medical Center (Z.D., L.H.), Division of Practice Advancement and Clinical Education, University of North Carolina Eshelman School of Pharmacy (Z.D., P.M., L.H.), Gillings School of Global Public Health (J.L., J.A., S.S.), and Department of Emergency Medicine (K.B.), University of North Carolina at Chapel Hill; and Department of Psychology (S.S.), Department of Cardiovascular Sciences (S.S.), and Department of Public Health (S.S.), East Carolina University, Greenville, NC
| | - James O'Bryan
- From the Division of Cardiology, Department of Medicine (A.G., P.M., T.J.W., S.C., J.O., K.G.), University of North Carolina Medical Center (Z.D., L.H.), Division of Practice Advancement and Clinical Education, University of North Carolina Eshelman School of Pharmacy (Z.D., P.M., L.H.), Gillings School of Global Public Health (J.L., J.A., S.S.), and Department of Emergency Medicine (K.B.), University of North Carolina at Chapel Hill; and Department of Psychology (S.S.), Department of Cardiovascular Sciences (S.S.), and Department of Public Health (S.S.), East Carolina University, Greenville, NC
| | - Kelly Garner
- From the Division of Cardiology, Department of Medicine (A.G., P.M., T.J.W., S.C., J.O., K.G.), University of North Carolina Medical Center (Z.D., L.H.), Division of Practice Advancement and Clinical Education, University of North Carolina Eshelman School of Pharmacy (Z.D., P.M., L.H.), Gillings School of Global Public Health (J.L., J.A., S.S.), and Department of Emergency Medicine (K.B.), University of North Carolina at Chapel Hill; and Department of Psychology (S.S.), Department of Cardiovascular Sciences (S.S.), and Department of Public Health (S.S.), East Carolina University, Greenville, NC
| | - Samuel F Sears
- From the Division of Cardiology, Department of Medicine (A.G., P.M., T.J.W., S.C., J.O., K.G.), University of North Carolina Medical Center (Z.D., L.H.), Division of Practice Advancement and Clinical Education, University of North Carolina Eshelman School of Pharmacy (Z.D., P.M., L.H.), Gillings School of Global Public Health (J.L., J.A., S.S.), and Department of Emergency Medicine (K.B.), University of North Carolina at Chapel Hill; and Department of Psychology (S.S.), Department of Cardiovascular Sciences (S.S.), and Department of Public Health (S.S.), East Carolina University, Greenville, NC
| | - Jill Akiyama
- From the Division of Cardiology, Department of Medicine (A.G., P.M., T.J.W., S.C., J.O., K.G.), University of North Carolina Medical Center (Z.D., L.H.), Division of Practice Advancement and Clinical Education, University of North Carolina Eshelman School of Pharmacy (Z.D., P.M., L.H.), Gillings School of Global Public Health (J.L., J.A., S.S.), and Department of Emergency Medicine (K.B.), University of North Carolina at Chapel Hill; and Department of Psychology (S.S.), Department of Cardiovascular Sciences (S.S.), and Department of Public Health (S.S.), East Carolina University, Greenville, NC
| | - Sally C Stearns
- From the Division of Cardiology, Department of Medicine (A.G., P.M., T.J.W., S.C., J.O., K.G.), University of North Carolina Medical Center (Z.D., L.H.), Division of Practice Advancement and Clinical Education, University of North Carolina Eshelman School of Pharmacy (Z.D., P.M., L.H.), Gillings School of Global Public Health (J.L., J.A., S.S.), and Department of Emergency Medicine (K.B.), University of North Carolina at Chapel Hill; and Department of Psychology (S.S.), Department of Cardiovascular Sciences (S.S.), and Department of Public Health (S.S.), East Carolina University, Greenville, NC
| | - Kevin Biese
- From the Division of Cardiology, Department of Medicine (A.G., P.M., T.J.W., S.C., J.O., K.G.), University of North Carolina Medical Center (Z.D., L.H.), Division of Practice Advancement and Clinical Education, University of North Carolina Eshelman School of Pharmacy (Z.D., P.M., L.H.), Gillings School of Global Public Health (J.L., J.A., S.S.), and Department of Emergency Medicine (K.B.), University of North Carolina at Chapel Hill; and Department of Psychology (S.S.), Department of Cardiovascular Sciences (S.S.), and Department of Public Health (S.S.), East Carolina University, Greenville, NC
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Kaufman BG, O'Brien EC, Stearns SC, Matsouaka RA, Holmes GM, Weinberger M, Schwamm LH, Smith EE, Fonarow GC, Xian Y, Taylor DH. Medicare Shared Savings ACOs and Hospice Care for Ischemic Stroke Patients. J Am Geriatr Soc 2019; 67:1402-1409. [DOI: 10.1111/jgs.15852] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2018] [Revised: 02/05/2019] [Accepted: 02/07/2019] [Indexed: 02/05/2023]
Affiliation(s)
- Brystana G. Kaufman
- Department of Health Policy and ManagementThe University of North Carolina at Chapel Hill Chapel Hill North Carolina
- Duke Margolis Center for Health Policy Durham North Carolina
| | - Emily C. O'Brien
- Department of Population Health SciencesDuke University Durham North Carolina
| | - Sally C. Stearns
- Department of Health Policy and ManagementThe University of North Carolina at Chapel Hill Chapel Hill North Carolina
- The Cecil G. Sheps Center for Health Services ResearchUniversity of North Carolina at Chapel Hill Chapel Hill North Carolina
| | - Roland A. Matsouaka
- Duke Clinical Research Institute Durham North Carolina
- Department of Biostatistics and BioinformaticsDuke University Durham North Carolina
| | - G. Mark Holmes
- Department of Health Policy and ManagementThe University of North Carolina at Chapel Hill Chapel Hill North Carolina
- The Cecil G. Sheps Center for Health Services ResearchUniversity of North Carolina at Chapel Hill Chapel Hill North Carolina
| | - Morris Weinberger
- Department of Health Policy and ManagementThe University of North Carolina at Chapel Hill Chapel Hill North Carolina
| | - Lee H. Schwamm
- Department of Neurology, Massachusetts General HospitalHarvard Medical School Boston Massachusetts
| | - Eric E. Smith
- Department of Neurology, Cumming School of MedicineUniversity of Calgary Calgary Canada
| | - Gregg C. Fonarow
- Division of CardiologyDavid Geffen School of Medicine at UCLA Los Angeles California
| | - Ying Xian
- Duke Clinical Research Institute Durham North Carolina
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Weintraub JA, Zimmerman S, Ward K, Wretman CJ, Sloane PD, Stearns SC, Poole P, Preisser JS. Improving Nursing Home Residents' Oral Hygiene: Results of a Cluster Randomized Intervention Trial. J Am Med Dir Assoc 2018; 19:1086-1091. [PMID: 30471800 PMCID: PMC6396648 DOI: 10.1016/j.jamda.2018.09.036] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [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: 09/21/2018] [Revised: 09/26/2018] [Accepted: 09/27/2018] [Indexed: 12/20/2022]
Abstract
OBJECTIVE A 2-year cluster randomized trial of Mouth Care Without a Battle (MCWB) was conducted in nursing homes (NHs) to determine if recommended mouth care practices provided by NH staff could improve residents' oral hygiene and denture outcomes. DESIGN Cluster randomized trial of NHs. SETTING AND PARTICIPANTS Seven MCWB NHs and 6 control NHs. A total of 219 NH residents completed baseline and 24-month oral examinations and, if applicable, denture assessments (control = 98, intervention = 121). INTERVENTION The intervention consisted of training NH staff in the MCWB protocol, and providing support in its use for 2 years. MEASURES Descriptive data from the Minimum Data Set and clinical oral health assessments: the Plaque Index for Long-Term Care (range 0‒3), the Gingival Index for Long-Term Care (range 0‒4), and the Denture Plaque Index (range 0‒4), with lower scores indicating better oral health. RESULTS There were no significant demographic or health differences between groups at baseline. Residents' mean age (standard deviation) was 77.8 years (13.5), 71% were female, and 49% had cognitive impairment. At 24 months, there were significant improvements in oral and denture hygiene in the intervention group compared with control (all P < .05) with mean changes in indices that were 0.44 (Plaque Index for Long-Term Care), 0.55 (Gingival Index for Long-Term Care), and 0.67 (Denture Plaque Index) points lower in intervention NHs than control NHs. CONCLUSIONS AND IMPLICATIONS FOR PRACTICE Training NH staff to attend to residents' oral hygiene and denture care had a sustained, favorable impact on residents' oral and denture hygiene after 24 months compared with usual care. The protocol, MCWB, can be used by direct caregivers to improve the oral hygiene and denture care of NH residents.
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Affiliation(s)
- Jane A Weintraub
- School of Dentistry, University of North Carolina at Chapel Hill, Chapel Hill, NC; Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC.
| | - Sheryl Zimmerman
- The Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill, Chapel Hill, NC; School of Social Work, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Kimberly Ward
- The Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Christopher J Wretman
- The Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Philip D Sloane
- The Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill, Chapel Hill, NC; Department of Family Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Sally C Stearns
- Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC; The Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Patricia Poole
- The Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - John S Preisser
- Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC
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22
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Witt LS, Rotter J, Stearns SC, Gottesman RF, Kucharska-Newton AM, Richey Sharrett A, Wruck LM, Bressler J, Sueta CA, Chang PP. Heart Failure and Cognitive Impairment in the Atherosclerosis Risk in Communities (ARIC) Study. J Gen Intern Med 2018; 33:1721-1728. [PMID: 30030736 PMCID: PMC6153245 DOI: 10.1007/s11606-018-4556-x] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [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: 12/01/2017] [Revised: 03/26/2018] [Accepted: 06/27/2018] [Indexed: 01/01/2023]
Abstract
BACKGROUND Previous studies suggest that heart failure (HF) is an independent risk factor for cognitive decline. A better understanding of the relationship between HF, cognitive status, and cognitive decline in a community-based sample may help clinicians understand disease risk. OBJECTIVE To examine whether persons with HF have a higher prevalence of cognitive impairment and whether persons developing HF have more rapid cognitive decline. DESIGN This observational cohort study of American adults in the Atherosclerosis Risk in Communities (ARIC) study has two components: cross-sectional analysis examining the association between prevalent HF and cognition using multinomial logistic regression, and change over time analysis detailing the association between incident HF and change in cognition over 15 years. PARTICIPANTS Among visit 5 (2011-2013) participants (median age 75 years), 6495 had neurocognitive information available for cross-sectional analysis. Change over time analysis examined the 5414 participants who had cognitive scores and no prevalent HF at visit 4 (1996-1998). MEASUREMENTS The primary outcome was cognitive status, classified as normal, mild cognitive impairment [MCI], and dementia on the basis of standardized cognitive tests (delayed word recall, word fluency, and digit symbol substitution). Cognitive change was examined over a 15-year period. Control variables included socio-demographic, vascular, and smoking/drinking measures. RESULTS At visit 5, participants with HF had a higher prevalence of dementia (adjusted relative risk ratio [RRR] = 1.60 [95% CI 1.13, 2.25]) and MCI (RRR = 1.36 [1.12, 1.64]) than those without HF. A decline in cognition between visits 4 and 5 was - 0.07 standard deviation units [- 0.13, - 0.01] greater among persons who developed HF compared to those who did not. Results did not differ by ejection fraction. CONCLUSION HF is associated with neurocognitive dysfunction and decline independent of other co-morbid conditions. Further study is needed to determine the underlying pathophysiology.
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Affiliation(s)
- Lucy S Witt
- Department of Hospital Medicine, Atlanta Veterans Affairs Medical Center, Decatur, GA, USA.
| | - Jason Rotter
- Department of Health Policy & Management, Gillings School of Global Public Health, The University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Sally C Stearns
- Cecil G. Sheps Center for Health Services Research, The University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Rebecca F Gottesman
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Anna M Kucharska-Newton
- Department of Epidemiology, Gillings School of Global Public Health, The University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - A Richey Sharrett
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Lisa M Wruck
- Duke Clinical Research Institute, Duke University, Durham, NC, USA
| | - Jan Bressler
- Human Genetics, and Environmental Sciences, University of Texas Health School of Public Health Department of Epidemiology, Austin, TX, USA
| | - Carla A Sueta
- Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Patricia P Chang
- Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
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Caughey MC, Sueta CA, Stearns SC, Shah AM, Rosamond WD, Chang PP. Recurrent Acute Decompensated Heart Failure Admissions for Patients With Reduced Versus Preserved Ejection Fraction (from the Atherosclerosis Risk in Communities Study). Am J Cardiol 2018; 122:108-114. [PMID: 29703442 DOI: 10.1016/j.amjcard.2018.03.011] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2017] [Revised: 03/02/2018] [Accepted: 03/06/2018] [Indexed: 12/12/2022]
Abstract
Hospitals are required to report all-cause 30-day readmissions for patients discharged with heart failure. Same-cause readmissions have received less attention but may differ for heart failure with reduced ejection fraction (HFrEF) versus heart failure with preserved ejection fraction (HFpEF). The ARIC study began abstracting medical records for cohort members hospitalized with acute decompensated heart failure (ADHF) in 2005. ADHF was validated by physician review, with HFrEF defined by ejection fraction <50%. Recurrent admissions for ADHF were analyzed within 30 days, 90 days, 6 months, and 1 year of the index hospitalization using repeat-measures Cox regression models. All recurrent ADHF admissions per patient were counted rather than the more typical analysis of only the first occurring readmission. From 2005 to 2014, 1,133 cohort members survived at least 1 hospitalization for ADHF and had ejection fraction recorded. Half were classified as HFpEF. Patients with HFpEF were more often women and had more co-morbidities. The overall ADHF readmission rate was greatest within 30 days of discharge but was higher for patients with HFrEF (115 vs 88 readmissions per 100 person-years). After adjustments for demographics, year of admission, and co-morbidities, there was a trend for higher ADHF readmissions with HFrEF, relative to HFpEF, at 30 days (hazard ratio [HR] 1.41, 95% confidence interval [CI] 0.92 to 2.18), 90 days (HR 1.39, 95% CI 1.05 to 1.85), 6 months (HR 1.47, 95% CI, 1.18 to 1.84), and 1 year (HR 1.42, 95% CI 1.18 to 1.70) of follow-up. In conclusion, patients with HFrEF have a greater burden of short- and long-term readmissions for recurrent ADHF.
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Abstract
Many elders require supportive services, with many costs covered by Medicaid. Once terminal illness sets in, palliative care and hospice may help control cost while ensuring quality. This commentary reviews trends in cost at the end of life and describes selected strategies to improve patient-centered care in North Carolina.
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Affiliation(s)
- Natalie C Ernecoff
- doctoral candidate, Department of Health Policy and Management, Gillings School of Global Public Health; research assistant, Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Sally C Stearns
- professor, Department of Health Policy and Management, Gillings School of Global Public Health; senior researcher, Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
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Dolin R, Holmes GM, Stearns SC, Kirk DA, Hanson LC, Taylor DH, Silberman P. A Positive Association Between Hospice Profit Margin And The Rate At Which Patients Are Discharged Before Death. Health Aff (Millwood) 2018; 36:1291-1298. [PMID: 28679817 DOI: 10.1377/hlthaff.2017.0113] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [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: 11/05/2022]
Abstract
Hospice care is designed to support patients and families through the final phase of illness and death. Yet for more than a decade, hospices have steadily increased the rate at which they discharge patients before death-a practice known as "live discharge." Although certain live discharges are consistent with high-quality care, regulators have expressed concern that some hospices' desire to maximize profits drives them to inappropriately discharge patients. We used Medicare claims data for 2012-13 and cost reports for 2011-13 to explore relationships between hospice-level financial margins and live discharge rates among freestanding hospices. Adjusted analyses showed positive and significant associations between both operating and total margins and hospice-level rates of live discharge: One-unit increases in operating and total margin were associated with increases of 3 percent and 4 percent in expected hospice-level live discharge rates, respectively. These findings suggest that additional research is needed to explore links between profitability and patient-centeredness in the Medicare hospice program.
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Affiliation(s)
- Rachel Dolin
- Rachel Dolin is a fellow at the David A. Winston Health Policy Fellowship, in Washington, D.C. Previously, she was a National Science Foundation Graduate Research Fellow in the Department of Health Policy and Management, Gillings School of Global Public Health, at the University of North Carolina at Chapel Hill (UNC)
| | - G Mark Holmes
- G. Mark Holmes is an associate professor in the Department of Health Policy and Management, Gillings School of Global Public Health, and director of the Cecil G. Sheps Center for Health Services Research, both at UNC
| | - Sally C Stearns
- Sally C. Stearns is a professor in the Department of Health Policy and Management, Gillings School of Global Public Health, UNC
| | - Denise A Kirk
- Denise A. Kirk is an applications analyst in the North Carolina Rural Health Research Program at the Cecil G. Sheps Center for Health Services Research, UNC
| | - Laura C Hanson
- Laura C. Hanson is a professor of medicine in the Division of Geriatric Medicine, associate director of the Geriatric Fellowship Program, and director of the Palliative Care Program, all at UNC
| | - Donald H Taylor
- Donald H. Taylor Jr. is a professor in the Sanford School of Public Policy, Duke University, in Durham, North Carolina
| | - Pam Silberman
- Pam Silberman is a professor of the practice and director of the Executive Doctoral Program in Health Leadership, Department of Health Policy and Management, Gillings School of Global Public Health, and associate director for policy analysis at the Cecil G. Sheps Center for Health Services Research, all at UNC
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Tran RH, Aldemerdash A, Chang P, Sueta CA, Kaufman B, Asafu-adjei J, Vardeny O, Daubert E, Alburikan KA, Kucharska-Newton AM, Stearns SC, Rodgers JE. Guideline-Directed Medical Therapy and Survival Following Hospitalization in Patients with Heart Failure. Pharmacotherapy 2018; 38:406-416. [PMID: 29423950 PMCID: PMC5902433 DOI: 10.1002/phar.2091] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
BACKGROUND Modification of guideline-directed medical therapy (GDMT) in hospitalized patients with heart failure (HF) has not been extensively evaluated. METHODS The community surveillance arm of the Atherosclerosis Risk in Communities Study identified 6959 HF hospitalizations from 2005-2011. Predictors of GDMT modification and survival were assessed using multivariable logistic regression and Cox proportional hazards models. RESULTS For 5091 hospitalizations, patient mean age was 75 years, 53% were female, 69% were white, and 81% had acute decompensated heart failure (ADHF). Regarding ejection fraction (EF), 31% of patients had HF with reduced EF (HFrEF), 24% had HF with preserved EF (HFpEF), and 44% were missing EF values. At admission, 52% of patients received angiotensin-converting enzyme inhibitors/angiotensin receptor blockers (ACEIs/ARBs), 66% β-blockers (BBs), 9% aldosterone-receptor antagonists, 16% digoxin, 10% hydralazine, and 29% nitrates. Modification of GDMT occurred in up to 23% of hospitalizations. Significant predictors of GDMT initiation included ADHF and HFrEF; discontinuation of medications was observed with select comorbidities. In HFrEF, initiation of any GDMT was associated with reduced 1-year all-cause mortality (adjusted hazard ratio [HR] 0.41, 95% confidence interval [CI] 0.23-0.71) as was initiation of ACEI/ARBs, BBs, and digoxin. Discontinuation of any therapy versus maintaining GDMT was associated with greater mortality (HR 1.30, 95% CI 1.02-1.66). Similar trends were observed in HFpEF. CONCLUSIONS Our study suggests that GDMT initiation is associated with increased survival, and discontinuation of therapy is associated with reduced survival in hospitalized patients with HF. Future studies should be conducted to confirm the impact of GDMT therapy modification in this population.
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Affiliation(s)
- Richard H. Tran
- Feasibility Strategist, Pharmaceutical Product Development, 3900 N Paramount Parkway, Morrisville, North Carolina 27560
| | - Ahmed Aldemerdash
- Assistant Professor of Clinical Pharmacy, King Saudi University, Riyadh 12372, Saudi Arabia
| | - Patricia Chang
- Associate Professor of Medicine, UNC School of Medicine, The University of North Carolina at Chapel Hill, Burnett-Womack CB#7075, Chapel Hill, North Carolina 27599
| | - Carla A. Sueta
- Associate Professor of Medicine, UNC School of Medicine, The University of North Carolina at Chapel Hill, Burnett-Womack CB#7075, Chapel Hill, North Carolina 27599
| | - Brystana Kaufman
- Research Assistant, Gillings School of Public Health, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina 27599-7411
| | - Josephine Asafu-adjei
- Research Assistant Professor, Gillings School of Public Health – Department of Biostatistics, The University of North Carolina at Chapel; Hill, McGavran-Greenberg Hall CB #7420, Chapel Hill, North Carolina 27599
| | - Orly Vardeny
- Associate Professor, University of Wisconsin – Madison School of Pharmacy, Rennebohm Hall, Madison, Wisconsin 53705
| | - Eliza Daubert
- Medical Information Scientist, United Therapeutics, 55 TW Alexander Drive, Durham, North Carolina 27709
| | - Khalid A. Alburikan
- Assistant Professor of Clinical Pharmacy, King Saud University, Riyadh 12372, Saudi Arabia
| | - Anna M. Kucharska-Newton
- Research Assistant Professor, Gillings School of Public Health, The University of North Carolina at Chapel Hill, 137 E. Franklin Street Suite 306, Chapel Hill, North Carolina 27514
| | - Sally C. Stearns
- Professor, Gillings School of Public Health, The University of North Carolina at Chapel, Chapel Hill, North Carolina 27599-7411
| | - Jo E. Rodgers
- Clinical Associate Professor, UNC Eshelman School of Pharmacy, The University of North Carolina at Chapel Hill, Kerr Hall CB#7569, Chapel Hill, North Carolina 27599
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27
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Dolin R, Silberman P, Kirk DA, Stearns SC, Hanson LC, Taylor DH, Holmes GM. Do Live Discharge Rates Increase as Hospices Approach Their Medicare Aggregate Payment Caps? J Pain Symptom Manage 2018; 55:775-784. [PMID: 29180057 DOI: 10.1016/j.jpainsymman.2017.11.018] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2017] [Revised: 11/15/2017] [Accepted: 11/17/2017] [Indexed: 10/18/2022]
Abstract
CONTEXT The rate of live discharge from hospice and the proportion of hospices exceeding their aggregate caps have both increased for the last 15 years, becoming a source of federal scrutiny. The cap restricts aggregate payments hospices receive from Medicare during a 12-month period. The risk of repayment and the manner in which the cap is calculated may incentivize hospices coming close to their cap ceilings to discharge existing patients before the end of the cap year. OBJECTIVE The objective of this work was to explore annual cap-risk trends and live discharge patterns. We hypothesized that as a hospice comes closer to exceeding its cap, a patient's likelihood of being discharged alive increases. METHODS We analyzed monthly hospice outcomes using 2012-2013 Medicare claims. RESULTS Adjusted analyses showed a positive and statistically significant relationship between cap risk and live discharges. CONCLUSION Policymakers ought to consider the unintended consequences the aggregate cap may be having on patient outcomes of care.
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Affiliation(s)
| | - Pam Silberman
- Department of Health Policy and Management, Gillings School of Global Public Health, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Denise A Kirk
- The Cecil G. Sheps Center for Health Services Research, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Sally C Stearns
- Department of Health Policy and Management, Gillings School of Global Public Health, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Laura C Hanson
- Palliative Care Program, Division of Geriatric Medicine, Center for Aging and Health, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Donald H Taylor
- Sanford School of Public Policy, Duke University, Durham, North Carolina, USA
| | - G Mark Holmes
- Department of Health Policy and Management, Gillings School of Global Public Health, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
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28
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Bush M, Stürmer T, Stearns SC, Simpson RJ, Brookhart MA, Rosamond W, Kucharska-Newton AM. Position matters: Validation of medicare hospital claims for myocardial infarction against medical record review in the atherosclerosis risk in communities study. Pharmacoepidemiol Drug Saf 2018; 27:1085-1091. [PMID: 29405474 DOI: 10.1002/pds.4396] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [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: 07/13/2017] [Revised: 10/18/2017] [Accepted: 12/18/2017] [Indexed: 11/10/2022]
Abstract
PURPOSE The objectives of this study were to investigate sensitivity and specificity of myocardial infarction (MI) case definitions using multiple discharge code positions and multiple diagnosis codes when comparing administrative data to hospital surveillance data. METHODS Hospital surveillance data for ARIC Study cohort participants with matching participant ID and service dates to Centers for Medicare and Medicaid Services (CMS) hospitalization records for hospitalizations occurring between 2001 and 2013 were included in this study. Classification of Definite or Probable MI from ARIC medical record review defined "gold standard" comparison for validation measures. In primary analyses, an MI was defined with ICD9 code 410 from CMS records. Secondary analyses defined MI using code 410 in combination with additional codes. RESULTS A total of 25 549 hospitalization records met study criteria. In primary analysis, specificity was at least 0.98 for all CMS definitions by discharge code position. Sensitivity ranged from 0.48 for primary position only to 0.63 when definition included any discharge code position. The sensitivity of definitions including codes 410 and 411.1 were higher than sensitivity observed when using code 410 alone. Specificity of these alternate definitions was higher for women (0.98) than for men (0.96). CONCLUSION Algorithms that rely exclusively on primary discharge code position will miss approximately 50% of all MI cases due to low sensitivity of this definition. We recommend defining MI by code 410 in any of first 5 discharge code positions overall and by codes 410 and 411.1 in any of first 3 positions for sensitivity analyses of women.
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Affiliation(s)
- Montika Bush
- University of North Carolina, Chapel Hill, NC, USA
| | - Til Stürmer
- University of North Carolina, Chapel Hill, NC, USA
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29
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Federspiel JJ, Sueta CA, Kucharska-Newton AM, Beyhaghi H, Zhou L, Virani SS, Rodgers JE, Chang PP, Stearns SC. Antihypertensive adherence and outcomes among community-dwelling Medicare beneficiaries: the Atherosclerosis Risk in Communities Study. J Eval Clin Pract 2018; 24:48-55. [PMID: 27807921 DOI: 10.1111/jep.12659] [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] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2016] [Revised: 08/31/2016] [Accepted: 09/02/2016] [Indexed: 11/30/2022]
Abstract
RATIONALE, AIMS, AND OBJECTIVES Despite proven benefits for reducing incidence of major cardiac events, antihypertensive drug therapy remains underutilized in the United States. This analysis assesses antihypertensive drug adherence, utilization predictors, and associations between adherence and outcomes (a composite of cardiovascular events, Medicare inpatient payments, and inpatient days). METHODS The sample consisted of Atherosclerosis Risk in Communities Study cohort participants reporting hypertension without prevalent cardiovascular disease during 2006 to 2007 annual follow-up calls. Atherosclerosis Risk in Communities records were linked to Medicare claims through 2012. Antihypertensive medication adherence was measured as more than 80% proportion days covered by using Medicare Part D claims. Standard and hierarchical regression models were used to evaluate adjusted associations between person characteristics and adherence and between adherence and outcomes. RESULTS Among 1826 hypertensive participants with Part D coverage, 31.5% had no antihypertensive class with more than 80% proportion days covered in the 3 months preceding the report of hypertension in 2006 to 2007. After adjustment for confounders, positive predictors of use included female gender and diabetes; negative predictors were African-American race and current smoking. Adjusted association between receiving no therapy and a composite endpoint of cardiovascular outcomes through 2012 was not statistically significant (hazard ratio: 0.93; 95% confidence interval: 0.72, 1.22) nor was the adjusted association with Medicare inpatient days or payments (incremental difference at 48 months in payments: $1217; 95% CI: -$2030, $4463). CONCLUSIONS Despite having medical and prescription coverage, nearly a third of hypertensive participants were not adherent to antihypertensive drug therapy. Differences in clinical outcomes associated with nonadherence, though not statistically significant, were consistent with results from randomized trials. The approach provides a model framework for rigorous assessment of detailed data that are increasingly available through emerging sources.
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Affiliation(s)
- Jerome J Federspiel
- Department of Health Policy and Management, The University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Carla A Sueta
- Division of Cardiology, Department of Medicine, The University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Anna M Kucharska-Newton
- Department of Epidemiology, The University of North Carolina at Chapel Hil, Chapel Hill, NC, USA
| | - Hadi Beyhaghi
- Department of Health Policy and Management, The University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Lei Zhou
- Lineberger Comprehensive Cancer Center, The University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Salim S Virani
- Michael E. DeBakey VA Medical Center & Baylor College of Medicine, Huston, TX, USA
| | - Jo E Rodgers
- Department of Pharmacotherapy and Experimental Therapeutics, UNC Eshelman School of Pharmacy, The University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Patricia P Chang
- Division of Cardiology, Department of Medicine, The University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Sally C Stearns
- Department of Health Policy and Management, The University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
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Biese KJ, Busby-Whitehead J, Cai J, Stearns SC, Roberts E, Mihas P, Emmett D, Zhou Q, Farmer F, Kizer JS. Telephone Follow-Up for Older Adults Discharged to Home from the Emergency Department: A Pragmatic Randomized Controlled Trial. J Am Geriatr Soc 2017; 66:452-458. [DOI: 10.1111/jgs.15142] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- Kevin J. Biese
- Department of Emergency Medicine; University of North Carolina; Chapel Hill North Carolina
- Center for Aging and Health; Department of Medicine; University of North Carolina at Chapel Hill; Chapel Hill North Carolina
| | - Jan Busby-Whitehead
- Center for Aging and Health; Department of Medicine; University of North Carolina at Chapel Hill; Chapel Hill North Carolina
| | - Jianwen Cai
- Department of Biostatistics; University of North Carolina at Chapel Hill; Chapel Hill North Carolina
| | - Sally C. Stearns
- Department of Health Policy and Management; University of North Carolina at Chapel Hill; Chapel Hill North Carolina
| | - Ellen Roberts
- Center for Aging and Health; Department of Medicine; University of North Carolina at Chapel Hill; Chapel Hill North Carolina
| | - Paul Mihas
- Howard W. Odum Institute for Research in Social Science; University of North Carolina at Chapel Hill; Chapel Hill North Carolina
| | - Doug Emmett
- Center for Aging and Health; Department of Medicine; University of North Carolina at Chapel Hill; Chapel Hill North Carolina
| | - Qingning Zhou
- Department of Biostatistics; University of North Carolina at Chapel Hill; Chapel Hill North Carolina
| | - Franklin Farmer
- Center for Aging and Health; Department of Medicine; University of North Carolina at Chapel Hill; Chapel Hill North Carolina
| | - John S. Kizer
- Center for Aging and Health; Department of Medicine; University of North Carolina at Chapel Hill; Chapel Hill North Carolina
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Kaufman BG, Spivack BS, Stearns SC, Song PH, O'Brien EC. Impact of Accountable Care Organizations on Utilization, Care, and Outcomes: A Systematic Review. Med Care Res Rev 2017; 76:255-290. [PMID: 29231131 DOI: 10.1177/1077558717745916] [Citation(s) in RCA: 74] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Since 2010, more than 900 accountable care organizations (ACOs) have formed payment contracts with public and private insurers in the United States; however, there has not been a systematic evaluation of the evidence studying impacts of ACOs on care and outcomes across payer types. This review evaluates the quality of evidence regarding the association of public and private ACOs with health service use, processes, and outcomes of care. The 42 articles identified studied ACO contracts with Medicare ( N = 24 articles), Medicaid ( N = 5), commercial ( N = 11), and all payers ( N = 2). The most consistent associations between ACO implementation and outcomes across payer types were reduced inpatient use, reduced emergency department visits, and improved measures of preventive care and chronic disease management. The seven studies evaluating patient experience or clinical outcomes of care showed no evidence that ACOs worsen outcomes of care; however, the impact on patient care and outcomes should continue to be monitored.
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Affiliation(s)
- Brystana G Kaufman
- 1 University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.,2 Duke Clinical Research Institute, Durham, NC, USA
| | - B Steven Spivack
- 1 University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Sally C Stearns
- 1 University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Paula H Song
- 1 University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
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Alburikan KA, Aldemerdash A, Savitz ST, Tisdale JE, Whitsel EA, Soliman EZ, Thudium EM, Sueta CA, Kucharska-Newton AM, Stearns SC, Rodgers JE. Contribution of medications and risk factors to QTc interval lengthening in the atherosclerosis risk in communities (ARIC) study. J Eval Clin Pract 2017; 23:1274-1280. [PMID: 28695724 PMCID: PMC5741511 DOI: 10.1111/jep.12776] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [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] [Received: 01/03/2017] [Revised: 04/29/2017] [Accepted: 05/01/2017] [Indexed: 12/17/2022]
Abstract
RATIONALE, AIMS, AND OBJECTIVES Prolongation of the corrected QT (QTc) interval is associated with increased morbidity and mortality. The association between QTc interval-prolonging medications (QTPMs) and risk factors with magnitude of QTc interval lengthening is unknown. We examined the contribution of risk factors alone and in combination with QTPMs to QTc interval lengthening. METHOD The Atherosclerosis Risk in Communities study assessed 15 792 participants with a resting, standard 12-lead electrocardiogram and ≥1 measure of QTc interval over 4 examinations at 3-year intervals (1987-1998). From 54 638 person-visits, we excluded participants with QRS ≥ 120 milliseconds (n = 2333 person-visits). We corrected the QT interval using the Bazett and Framingham formulas. We examined QTc lengthening using linear regression for 36 602 person-visit observations for 14 160 cohort members controlling for age ≥ 65 years, female sex, left ventricular hypertrophy, QTc > 500 milliseconds at the prior visit, and CredibleMeds categorized QTPMs (Known, Possible, or Conditional risk). We corrected standard errors for repeat observations per person. RESULTS Eighty percent of person-visits had at least one risk factor for QTc lengthening. Use of QTPMs increased over the 4 visits from 8% to 17%. Among persons not using QTPMs, history of prolonged QTc interval and female sex were associated with the greatest QTc lengthening, 39 and 12 milliseconds, respectively. In the absence of risk factors, Known QTPMs and ≥2 QTPMs were associated with modest but greater QTc lengthening than Possible or Conditional QTPMs. In the presence of risk factors, ≥2 QTPM further increased QTc lengthening. In combination with risk factors, the association of all QTPM categories with QTc lengthening was greater than QTPMs alone. CONCLUSION Risk factors, particularly female sex and history of prolonged QTc interval, have stronger associations with QTc interval lengthening than any QTPM category alone. All QTPM categories augmented QTc interval lengthening associated with risk factors.
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Affiliation(s)
| | - Ahmed Aldemerdash
- UNC Eshelman School of Pharmacy, The University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Samuel T Savitz
- Gillings School of Global Public Health, The University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - James E Tisdale
- College of Pharmacy, Purdue University, Indianapolis, IN, USA
| | - Eric A Whitsel
- Gillings School of Global Public Health, The University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.,School of Medicine, The University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | | | | | - Carla A Sueta
- School of Medicine, The University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Anna M Kucharska-Newton
- Gillings School of Global Public Health, The University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Sally C Stearns
- Gillings School of Global Public Health, The University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Jo E Rodgers
- UNC Eshelman School of Pharmacy, The University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
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Savitz ST, Stearns SC, Groves JS, Kucharska-Newton AM, Bengtson LGS, Wruck L. Mind the Gap: Hospitalizations from Multiple Sources in a Longitudinal Study. Value Health 2017; 20:777-784. [PMID: 28577695 PMCID: PMC5458617 DOI: 10.1016/j.jval.2016.04.012] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/07/2015] [Revised: 02/26/2016] [Accepted: 04/25/2016] [Indexed: 06/07/2023]
Abstract
BACKGROUND Medicare claims and prospective studies with self-reported utilization are important sources of hospitalization data for epidemiologic and outcomes research. OBJECTIVES To assess the concordance of Medicare claims merged with interview-based surveillance data to determine factors associated with source completeness. METHODS The Atherosclerosis Risk in Communities (ARIC) study recruited 15,792 cohort participants aged 45 to 64 years in the period 1987 to 1989 from four communities. Hospitalization records obtained through cohort report and hospital record abstraction were matched to Medicare inpatient records (MedPAR) from 2006 to 2011. Factors associated with concordance were assessed graphically and using multinomial logit regression. RESULTS Among fee-for-service enrollees, MedPAR and ARIC hospitalizations matched approximately 67% of the time. For Medicare Advantage enrollees, completeness increased after initiation of hospital financial incentives in 2008 to submit shadow bills for Medicare Advantage enrollees. Concordance varied by geographic site, age, veteran status, proximity to death, study attrition, and whether hospitalizations were within ARIC catchment areas. CONCLUSIONS ARIC and MedPAR records had good concordance among fee-for-service enrollees, but many hospitalizations were available from only one source. MedPAR hospital records may be missing for veterans or observation stays. Maintaining study participation increases stay completeness, but new sources such as electronic health records may be more efficient than surveillance for mobile elderly populations.
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Affiliation(s)
- Samuel T Savitz
- Department of Health Policy and Management, The University of North Carolina at Chapel Hill, Chapel Hill, NC, USA; The Cecil G. Sheps Center for Health Services Research, The University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.
| | - Sally C Stearns
- Department of Health Policy and Management, The University of North Carolina at Chapel Hill, Chapel Hill, NC, USA; The Cecil G. Sheps Center for Health Services Research, The University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Jennifer S Groves
- The Cecil G. Sheps Center for Health Services Research, The University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Anna M Kucharska-Newton
- The Cecil G. Sheps Center for Health Services Research, The University of North Carolina at Chapel Hill, Chapel Hill, NC, USA; Department of Epidemiology, The University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | | | - Lisa Wruck
- Duke Clinical Research Institute, Duke University, Durham, NC, USA
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Dolin R, Hanson LC, Rosenblum SF, Stearns SC, Holmes GM, Silberman P. Factors Driving Live Discharge From Hospice: Provider Perspectives. J Pain Symptom Manage 2017; 53:1050-1056. [PMID: 28323079 DOI: 10.1016/j.jpainsymman.2017.02.004] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2016] [Revised: 02/06/2017] [Accepted: 02/08/2017] [Indexed: 11/21/2022]
Abstract
CONTEXT The proportion of patients disenrolling from hospice before death has increased over the decade with significant variations across hospice types and regions. Such trends have raised concerns about live disenrollment's effect on care quality. Live disenrollment may be driven by factors other than patient preference and may create discontinuities in care, disrupting ongoing patient-provider relationships. Researchers have not explored when and how providers make this decision with patients. OBJECTIVE The objective of this study was to ascertain provider perspectives on key drivers of live discharge from the Medicare hospice program. METHODS We conducted semistructured telephone interviews with 18 individuals representing 14 hospice providers across the country. Transcriptions were coded and analyzed using a template analysis approach. RESULTS Analysis generated four themes: 1) difficulty estimating patient prognosis, 2) fear of Centers for Medicare & Medicaid Services audits, 3) rising market competition, and 4) challenges with inpatient contracting. Participants emphasized challenges underlying each decision to discharge patients alive, stressing that there often exists a gray line between appropriate and inappropriate discharges. Discussions also focused on scenarios in which financial motivations drive enrollment and disenrollment practices. CONCLUSION This study provides significant contributions to existing knowledge about hospice enrollment and disenrollment patterns. Results suggest that live discharge patterns are often susceptible to market and regulatory forces, which may have contributed to the rising national rate.
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Affiliation(s)
- Rachel Dolin
- Department of Health Policy and Management, Gillings School of Global Public Health, The University of North Carolina at Chapel Hill, North Carolina, USA.
| | - Laura C Hanson
- Division of Geriatric Medicine, Center for Aging and Health, Palliative Care Program, The University of North Carolina at Chapel Hill, North Carolina, USA
| | | | - Sally C Stearns
- Department of Health Policy and Management, Gillings School of Global Public Health, The University of North Carolina at Chapel Hill, North Carolina, USA
| | - George M Holmes
- Department of Health Policy and Management, Gillings School of Global Public Health, The University of North Carolina at Chapel Hill, North Carolina, USA
| | - Pam Silberman
- Department of Health Policy and Management, Gillings School of Global Public Health, The University of North Carolina at Chapel Hill, North Carolina, USA
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Maynard A, Altman SH, Stearns SC. Redistribution and redesign in health care: An ebbing tide in England versus growing concerns in the United States. Health Econ 2017; 26:687-690. [PMID: 28470833 DOI: 10.1002/hec.3516] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/01/2017] [Accepted: 03/16/2017] [Indexed: 06/07/2023]
Affiliation(s)
- Alan Maynard
- Department of Health Sciences, University of York, York, UK
| | - Stuart H Altman
- The Heller School for Social Policy and Management, Brandeis University, Waltham, MA, USA
- Department of Health Policy and Management, The University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Sally C Stearns
- Department of Health Policy and Management, The University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
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Rodgers JE, Thudium EM, Beyhaghi H, Sueta CA, Alburikan KA, Kucharska-Newton AM, Chang PP, Stearns SC. Predictors of Medication Adherence in the Elderly: The Role of Mental Health. Med Care Res Rev 2017; 75:746-761. [PMID: 29148336 DOI: 10.1177/1077558717696992] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [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: 11/17/2022]
Abstract
The aging population routinely has comorbid conditions requiring complicated medication regimens, yet nonadherence can preclude optimal outcomes. This study explored the association of adherence in the elderly with demographic, socioeconomic, and disease burden measures. Data were from the fifth visit (2011-2013) for 6,538 participants in the Atherosclerosis Risk in Communities Study, conducted in four communities. The Morisky-Green-Levine Scale measured self-reported adherence. Forty percent of respondents indicated some nonadherence, primarily due to poor memory. Logit regression showed, surprisingly, that persons with low reading ability were more likely to report being adherent. Better self-reported physical or mental health both predicted better adherence, but the magnitude of the association was greater for mental than for physical health. Compared with persons with normal or severely impaired cognition, mild cognitive impairment was associated with lower adherence. Attention to mental health measures in clinical settings could provide opportunities for improving medication adherence.
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Affiliation(s)
- Jo E Rodgers
- 1 Eshelman School of Pharmacy, The University of North Carolina at Chapel Hill, NC, USA
| | - Emily M Thudium
- 1 Eshelman School of Pharmacy, The University of North Carolina at Chapel Hill, NC, USA
| | - Hadi Beyhaghi
- 2 Gillings School of Global Public Health, The University of North Carolina at Chapel Hill, NC, USA
| | - Carla A Sueta
- 3 School of Medicine, The University of North Carolina at Chapel Hill, NC, USA
| | - Khalid A Alburikan
- 4 College of Pharmacy, King Saud University, Riyadh, Kingdom of Saudi Arabia
| | - Anna M Kucharska-Newton
- 2 Gillings School of Global Public Health, The University of North Carolina at Chapel Hill, NC, USA
| | - Patricia P Chang
- 3 School of Medicine, The University of North Carolina at Chapel Hill, NC, USA
| | - Sally C Stearns
- 2 Gillings School of Global Public Health, The University of North Carolina at Chapel Hill, NC, USA
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Beyhaghi H, Reeve BB, Rodgers JE, Stearns SC. Psychometric Properties of the Four-Item Morisky Green Levine Medication Adherence Scale among Atherosclerosis Risk in Communities (ARIC) Study Participants. Value Health 2016; 19:996-1001. [PMID: 27987650 PMCID: PMC5287458 DOI: 10.1016/j.jval.2016.07.001] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/28/2015] [Revised: 06/25/2016] [Accepted: 07/02/2016] [Indexed: 06/06/2023]
Abstract
OBJECTIVES To evaluate the reliability and factorial validity of the four-item Morisky Green Levine Medication Adherence Scale (MGLS) among Atherosclerosis Risk in Communities (ARIC) Study participants. METHODS We used the cross-sectional visit 5 data from the ARIC Study to assess the measurement properties of the MGLS. We measured the internal consistency using Cronbach α (where α > 0.70 is considered reliable for group-level measurement), the response frequency, and the inter item correlation. Factor analysis of the MGLS and five other adherence items in the survey was conducted using a polychoric correlation matrix to examine the dimensionality that underlies the MGLS. A vanishing tetrad test was conducted to assess conformity with an effect indicator model. RESULTS Among the ARIC visit 5 participants, 6,261 (96%) responded to the MGLS and other questions related to medication adherence in the survey (mean age 76 ± 5 years, 59% women). The Cronbach α for the MGLS was 0.47. The inter-item correlations ranged from 0.11 to 0.26. In the factor analysis of the medication adherence survey questions, a three-factor solution was used. One factor captured the extent of nonadherence, whereas other factors focused on the reasons for nonadherence. The MGLS items spread out across the factors that reflect the extent of as well as the reasons for nonadherence. The results of the vanishing tetrad test indicated that the MGLS consists of items other than effect indicators (P < 0.0001). CONCLUSIONS The low reliability together with the factor analysis findings imply that the MGLS may reflect causes as well as the extent of medication adherence. The findings suggest that the MGLS, as presently used, lacks consistency in an elderly population.
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Affiliation(s)
- Hadi Beyhaghi
- Department of Health Policy and Management, Gillings School of Global Public Health, the University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.
| | - Bryce B Reeve
- Department of Health Policy and Management, Gillings School of Global Public Health, the University of North Carolina at Chapel Hill, Chapel Hill, NC, USA; Cecil G. Sheps Center for Health Services Research, the University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Jo E Rodgers
- Division of Pharmacotherapy and Experimental Therapeutics, Eshelman School of Pharmacy, the University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Sally C Stearns
- Department of Health Policy and Management, Gillings School of Global Public Health, the University of North Carolina at Chapel Hill, Chapel Hill, NC, USA; Cecil G. Sheps Center for Health Services Research, the University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
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Kaufman BG, Sueta CA, Chen C, Windham BG, Stearns SC. Are Trends in Hospitalization Prior to Hospice Use Associated With Hospice Episode Characteristics? Am J Hosp Palliat Care 2016; 34:860-868. [PMID: 27418598 DOI: 10.1177/1049909116659049] [Citation(s) in RCA: 6] [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] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
This study expands current knowledge of factors associated with initiation of hospice care by examining prehospice patterns of medical care leading to Medicare hospice use and the relationships to hospice episode characteristics. Data from the Atherosclerosis Risk in Communities (ARIC) study cohort offer the ability to control for measures that are not available in Medicare claims data, including marital status, nursing home residency, and education. For 1248 ARIC participants who used hospice (2006-2012), participant level trends in the number of hospital days per 30-day period over the year prior to hospice initiation were generated using a fixed-effects model. Logistic regression was used to estimate the associations between increasing hospital use over the year prior to hospice enrollment with key patient characteristics (diagnosis, age, and comorbidity) and episode characteristics (short hospice stay ending in death, long hospice stay, and live discharge). Participants with severe comorbidity (measured as a Charlson comorbidity index score greater than 5) had higher odds of increasing hospital use prior to hospice (odds ratio [OR] = 3.28, confidence interval [CI] = 2.25-4.78). Increasing hospital use did not vary by diagnosis but was associated with reduced odds of a live hospice discharge (OR = 0.55, CI = 0.34-0.88) or long stay in hospice (OR = 0.44, CI = 0.24-0.79) and increased odds of a short stay in hospice (OR = 1.92, CI = 1.36-2.71). The evidence that care patterns prior to hospice use are associated with hospice outcomes could facilitate development of interventions to improve timely hospice referral.
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Affiliation(s)
- Brystana G Kaufman
- 1 Department of Health Policy and Management, The University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Carla A Sueta
- 2 Division of Cardiology, The University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Cathy Chen
- 3 University of Mississippi Medical Center, Jackson, MS, USA
| | - B Gwen Windham
- 3 University of Mississippi Medical Center, Jackson, MS, USA
| | - Sally C Stearns
- 1 Department of Health Policy and Management, The University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
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Konetzka RT, Stearns SC, Konrad TR, Magaziner J, Zimmerman S. Personal Care Aide Turnover in Residential Care Settings: An Assessment of Ownership, Economic, and Environmental Factors. J Appl Gerontol 2016. [DOI: 10.1177/0733464804270854] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Turnover among personal care aides is a chronic problem facing long-term-care industries. High turnover leads to high recruitment and training costs and to the potential for substandard care. Studies in nursing homes have found environmental factors to be more important than economic factors in predicting turnover rates, but no studies have been done in an assisted living setting or have considered the effects of the physical environment and location of the facility. This study assesses the importance of a variety of factors on turnover among personal care aides, using a two-part model. The results show that certain ownership and environmental factors (facility type, chain ownership, and attractiveness of the neighborhood)are important predictors of turnover. Although adequate economic compensation is undoubtedly important in attracting and retaining qualified staff, the results identify facility characteristics that may indicate a greater level of turnover as well as greater potential for improvement through interventions to reduce turnover.
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Schneider ALC, Kalyani RR, Golden S, Stearns SC, Wruck L, Yeh HC, Coresh J, Selvin E. Diabetes and Prediabetes and Risk of Hospitalization: The Atherosclerosis Risk in Communities (ARIC) Study. Diabetes Care 2016; 39:772-9. [PMID: 26953170 PMCID: PMC4839170 DOI: 10.2337/dc15-1335] [Citation(s) in RCA: 54] [Impact Index Per Article: 6.8] [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: 06/25/2015] [Accepted: 02/09/2016] [Indexed: 02/03/2023]
Abstract
OBJECTIVE To examine the magnitude and types of hospitalizations among persons with prediabetes, undiagnosed diabetes, and diagnosed diabetes. RESEARCH DESIGN AND METHODS This study included 13,522 participants in the Atherosclerosis Risk in Communities (ARIC) study (mean age 57 years, 56% female, 24% black, 18% with prediabetes, 4% with undiagnosed diabetes, 9% with diagnosed diabetes) with follow-up in 1990-2011 for hospitalizations. Participants were categorized by diabetes/HbA1c status: without diagnosed diabetes, HbA1c <5.7% (reference); prediabetes, 5.7 to <6.5%; undiagnosed diabetes, ≥6.5%; and diagnosed diabetes, <7.0 and ≥7.0%. RESULTS Demographic adjusted rates per 1,000 person-years of all-cause hospitalizations were higher with increasing diabetes/HbA1c category (Ptrend < 0.001). Persons with diagnosed diabetes and HbA1c ≥7.0% had the highest rates of hospitalization (3.1 times higher than those without a history of diagnosed diabetes, HbA1c <5.7%, and 1.5 times higher than those with diagnosed diabetes, HbA1c <7.0%, P < 0.001 for both comparisons). Persons with undiagnosed diabetes had 1.6 times higher rates of hospitalization and those with prediabetes had 1.3 times higher rates of hospitalization than those without diabetes and HbA1c <5.7% (P < 0.001 for both comparisons). Rates of hospitalization by diabetes/HbA1c category were different by race (Pinteraction = 0.011) and by sex (Pinteraction = 0.020). There were significantly excess rates of hospitalizations due to cardiovascular, endocrine, respiratory, gastrointestinal, iatrogenic/injury, neoplasm, genitourinary, neurologic, and infection causes among those with diagnosed diabetes compared with those without a history of diagnosed diabetes (all P < 0.05). CONCLUSIONS Persons with diagnosed diabetes, undiagnosed diabetes, and prediabetes are at a significantly elevated risk of hospitalization compared with those without diabetes. Substantial excess rates of hospitalizations in persons with diagnosed diabetes were for endocrine, infection, and iatrogenic/injury causes, which may be preventable with improved diabetes care.
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Affiliation(s)
- Andrea L C Schneider
- Department of Epidemiology, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Rita R Kalyani
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Sherita Golden
- Department of Epidemiology, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Sally C Stearns
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Lisa Wruck
- Department of Biostatistics, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Hsin Chieh Yeh
- Department of Epidemiology, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Josef Coresh
- Department of Epidemiology, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Elizabeth Selvin
- Department of Epidemiology, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
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Zuckerman RB, Stearns SC, Sheingold SH. Hospice Use, Hospitalization, and Medicare Spending at the End of Life. J Gerontol B Psychol Sci Soc Sci 2015; 71:569-80. [PMID: 26655645 DOI: 10.1093/geronb/gbv109] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [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: 03/04/2015] [Accepted: 10/26/2015] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVES Prior studies associate hospice use with reduced hospitalization and spending at the end of life based on all Medicare hospice beneficiaries. In this study, we examine the impact of different lengths of hospice care and nursing home residency on hospital use and spending prior to death across 5 disease groups. METHODS We compared inpatient hospital days and Medicare spending during the last 6 months of life using hospice versus propensity matched non-hospice beneficiaries who died in 2010, were enrolled in fee for service Medicare throughout the last 2 years of life, and were in at least 1 of 5 disease groups. Comparisons were based on length of hospice use and whether the decedent was in a nursing home during the seventh month prior to death. We regressed a categorical measure of hospice days on outcomes, controlling for observed patient characteristics. RESULTS Hospice use over 2 weeks was associated with decreased hospital days (1-5 days overall, with greater decreases for longer hospice use) for all beneficiaries; spending was $900-$5,000 less for hospice use of 31-90 days for most beneficiaries not in nursing homes, except beneficiaries with Alzheimer's. Overall spending decreased with hospice use for beneficiaries in nursing homes with lung cancer only, with a $3,500 reduction. DISCUSSION The Medicare hospice benefit is associated with reduced hospital care at the end of life and reduced Medicare expenditures for most enrollees. Policies that encourage timely initiation of hospice and discourage extremely short stays could increase these successes while maintaining program goals.
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Affiliation(s)
- Rachael B Zuckerman
- Office of Health Policy, Office of the Assistant Secretary for Planning and Evaluation, United States Department of Health and Human Services, Washington, District of Columbia. Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland.
| | - Sally C Stearns
- Department of Health Policy and Management, The University of North Carolina at Chapel Hill, Chapel Hill
| | - Steven H Sheingold
- Office of Health Policy, Office of the Assistant Secretary for Planning and Evaluation, United States Department of Health and Human Services, Washington, District of Columbia
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Sueta CA, Rodgers JE, Chang PP, Zhou L, Thudium EM, Kucharska-Newton AM, Stearns SC. Medication Adherence Based on Part D Claims for Patients With Heart Failure After Hospitalization (from the Atherosclerosis Risk in Communities Study). Am J Cardiol 2015; 116:413-9. [PMID: 26026867 DOI: 10.1016/j.amjcard.2015.04.058] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [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: 01/16/2015] [Revised: 04/25/2015] [Accepted: 04/25/2015] [Indexed: 11/15/2022]
Abstract
Medication nonadherence is a common precipitant of heart failure (HF) hospitalization and is associated with poor outcomes. Recent analyses of national data focus on long-term medication adherence. Little is known about adherence of patients with HF immediately after hospitalization. Hospitalized patients with HF were identified from the Atherosclerosis Risk in Communities study. Atherosclerosis Risk in Communities data were linked to Medicare inpatient and part D claims from 2006 to 2009. Inclusion criteria were a chart-adjudicated diagnosis of acute decompensated or chronic HF; documentation of angiotensin-converting enzyme inhibitor/angiotensin receptor blocker (ACEI/ARB), β blocker (BB), or diuretic prescription at discharge; and Medicare part D coverage. Proportion of ambulatory days covered was calculated for up to twelve 30-day periods after discharge. Adherence was defined as ≥80% proportion of ambulatory days covered. We identified 402 participants with Medicare part D: mean age 75, 30% men, and 41% black. Adherence at 1, 3, and 12 months was 70%, 61%, and 53% for ACEI/ARB; 76%, 66%, and 62% for BB; and 75%, 68%, and 59% for diuretic. Adherence to any single drug class was positively correlated with being adherent to other classes. Adherence varied by geographic site/race for ACEI/ARB and BB but not diuretics. In conclusion, despite having part D coverage, medication adherence after discharge for all 3 medication classes decreases over 2 to 4 months after discharge, followed by a plateau over the subsequent year. Interventions should focus on early and sustained adherence.
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Affiliation(s)
- Carla A Sueta
- Division of Cardiology, UNC Center for Heart and Vascular Care, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina.
| | - Jo E Rodgers
- Division of Phamacotherapy and Experimental Therapeutics, UNC Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Patricia P Chang
- Division of Cardiology, UNC Center for Heart and Vascular Care, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Lei Zhou
- Lineberger Cancer Research Center, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Emily M Thudium
- Division of Phamacotherapy and Experimental Therapeutics, UNC Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Anna M Kucharska-Newton
- Department of Epidemiology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Sally C Stearns
- Department of Health Policy and Management, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
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Kucharska-Newton AM, Heiss G, Ni H, Stearns SC, Puccinelli-Ortega N, Wruck LM, Chambless L. Identification of Heart Failure Events in Medicare Claims: The Atherosclerosis Risk in Communities (ARIC) Study. J Card Fail 2015. [PMID: 26211720 DOI: 10.1016/j.cardfail.2015.07.013] [Citation(s) in RCA: 50] [Impact Index Per Article: 5.6] [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] [Indexed: 11/18/2022]
Abstract
BACKGROUND We examined the accuracy of Medicare heart failure (HF) diagnostic codes in the identification of acute decompensated (ADHF and chronic stable (CSHF) HF. METHODS AND RESULTS Hospitalizations were identified from medical discharge records for Atherosclerosis Risk in Communities (ARIC) study participants with linked Medicare Provider Analysis and Review (MedPAR) files for the years 2005-2009. The ARIC study classification of ADHF and CSHF, based on adjudicated review of medical records, was considered to be the criterion standard. A total 8,239 ARIC medical records and MedPAR records meeting fee-for-service (FFS) criteria matched on unique participant ID and date of discharge (68.5% match). Agreement between HF diagnostic codes from the 2 data sources found in the matched records for codes in any position (κ > 0.9) was attenuated for primary diagnostic codes (κ < 0.8). Sensitivity of HF diagnostic codes found in Medicare claims in the identification of ADHF and CSHF was low, especially for the primary diagnostic codes. CONCLUSION Matching of hospitalizations from Medicare claims with those obtained from abstracted medical records is incomplete, even for hospitalizations meeting FFS criteria. Within matched records, HF diagnostic codes from Medicare show excellent agreement with HF diagnostic codes obtained from medical record abstraction. The Medicare data may, however, overestimate the occurrence of hospitalized ADHF or CSHF.
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Affiliation(s)
| | - Gerardo Heiss
- Department of Epidemiology, University of North Carolina, Chapel Hill, North Carolina
| | - Hanyu Ni
- Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Sally C Stearns
- Department of Health Policy and Management, University of North Carolina, Chapel Hill, North Carolina
| | | | - Lisa M Wruck
- Department of Biostatistics, University of North Carolina, Chapel Hill, North Carolina
| | - Lloyd Chambless
- Department of Biostatistics, University of North Carolina, Chapel Hill, North Carolina
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Alburikan KA, Savitz ST, Whitsel EAWA, Tisdale JE, Soliman EZ, Kucharska-Newton AM, Stearns SC, Rodgers JE. Abstract 141: Predictors of the Utilization of QT Interval Lengthening Medications in the Atherosclerosis Risk in Communities (ARIC) Study. Circ Cardiovasc Qual Outcomes 2015. [DOI: 10.1161/circoutcomes.8.suppl_2.141] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Objective:
Prolongation of corrected QT interval (QTc) is associated with increased morbidity and mortality. We examined the predictors of the use of QTc prolonging medications (QTPM).
Methods:
We included 15,792 ARIC participants with a resting, standard 12-lead electrocardiogram and ≥ 1 measure of QTc over up to four triennial examinations between 1987 and 1998 (54,638 person-visits). Participants with missing data were excluded (n=1,668). To optimize clinical applicability, QTc was calculated using Bazett’s equation. At each visit, we identified participants using ≥ 1 CredibleMeds classified QTPMs, age > 65 years, females, and those with LVH, or QTc > 500 ms at the prior visit. We used linear regression (random and fixed effects models) for 37,233 person-visit observations from visits 2-4 to determine predictors of the use of QTPMs. The following known risk factors and potential predictors for QTc lengthening were assessed: age, female sex, LVH, and QTc at the prior visit. Standard errors were corrected for repeat observations per person. Additional risk factors will be assessed in future analyses.
Results:
Among person-visit observations from Visit 2-4 (mean age 59.7, 55% female, 9% LVH, mean QTc 431), 16% (n= 5,153) of participants were using one or more QTPM. Preliminary results suggest three of the four identified risk factors predicted use of QTPMs: age, sex, and QTc at prior visit. Prolonged QTc at prior visit was associated with a lower probability of using QTPM. In contrast, use of QTPMs was positively associated with a joint effect of age and female sex. The latter is concerning given older females are at increased risk for QTc prolongation.
Conclusions:
In this preliminary analysis, several predictors of QTPM use emerged. Future analyses will include additional predictors and assessment of outcome will adjust for these predictors.
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Stearns SC, Rodgers JE, Chang PP, Sueta CA. Abstract 118: Discharge Medications, Hospice Use and 30 Day Outcomes for Hospitalized Heart Failure Patients. Circ Cardiovasc Qual Outcomes 2015. [DOI: 10.1161/circoutcomes.8.suppl_2.118] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Purpose:
Identifying factors associated with poor 30 day outcomes following hospital discharge for heart failure patients is important for improving quality of care. Discharge on appropriate medications is a critical factor to improve outcomes. Analyses generally have not differentiated discharge medication recommendations based on prognosis such as referral to hospice after discharge.
Methods:
Hospitalized Medicare patients with an adjudicated acute HF diagnosis during 2006-2011 were identified from the Atherosclerosis Risk in Communities (ARIC) study of a biracial cohort of 15,792 participants from 4 US communities since 1987. Logistic regression was used to explore two questions: 1) whether using hospice within 30 days of discharge was associated with being discharged on at least one of three medications [ACE inhibitors/angiotensin receptor blockers (ACEI/ARB), beta-blockers (BB), or diuretics]; and 2) how inclusion of patients likely close to death affected associations of discharge medications (separately or in combination) with hospital readmission or death within 30 days. Hospitalizations for participants who used hospice and died within 30 days following discharge were excluded for the analysis of readmission or death. All regressions controlled for patient demographic and clinical characteristics.
Results:
The study sample included 780 participants (mean age 76, 45% male, 35% black) with 1457 hospital discharges; within 30 days, 24% of discharges were readmitted and 5% died. Hospice was used within 30 days for 105 discharges (7.4%). Using hospice was strongly associated with not being discharged on at least one medication (OR 0.22; 95% CI 0.11,0.46). Forty discharges used hospice and died within 30 days but only 26 had complete data. Excluding these cases, regression with complete data for 1240 hospitalizations (684 patients) showed that thirty day readmission or death was lower (p<0.05) for patients discharged on ACEI/ARB (OR 0.71, 95% CI 0.53,0.95) or diuretics (OR 0.66, 95% CI 0.48,0.91) but not for BB. A regression assessing the joint effect of discharge on all three drugs had the strongest reduction (OR 0.56, 95% CI 0.41,0.76); including hospice users who died within 30 days without readmission showed only a slightly stronger effect (OR 0.53, 95% CI 0.39,0.72), possibly due to the addition of only 26 stays. Other predictors positively associated with readmission or death included race/site, atrial fibrillation, stroke, and longer hospital stay; hospice was weakly associated with a lower likelihood.
Conclusions:
As heart failure progresses, transfer to palliative or hospice services is often appropriate. Including patients when death is imminent in outcome analyses could overestimate medication effects. Mechanisms for identifying such patients other than hospice use are limited but constitute an important goal for future research.
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Affiliation(s)
| | - Jo E Rodgers
- The Univ of North Carolina at Chapel Hill, Chapel Hill, NC
| | | | - Carla A Sueta
- The Univ of North Carolina at Chapel Hill, Chapel Hill, NC
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46
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Geissler K, Stearns SC, Becker C, Thirumurthy H, Holmes GM. The relationship between violence in Northern Mexico and potentially avoidable hospitalizations in the USA-Mexico border region. J Public Health (Oxf) 2015; 38:14-23. [PMID: 25698793 DOI: 10.1093/pubmed/fdv012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [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: 11/12/2022] Open
Abstract
BACKGROUND Substantial proportions of US residents in the USA-Mexico border region cross into Mexico for health care; increases in violence in northern Mexico may have affected this access. We quantified associations between violence in Mexico and decreases in access to care for border county residents. We also examined associations between border county residence and access. METHODS We used hospital inpatient data for Arizona, California and Texas (2005-10) to estimate associations between homicide rates and the probability of hospitalization for ambulatory care sensitive (ACS) conditions. Hospitalizations for ACS conditions were compared with homicide rates in Mexican municipalities matched by patient residence. RESULTS A 1 SD increase in the homicide rate of the nearest Mexican municipality was associated with a 2.2 percentage point increase in the probability of being hospitalized for an ACS condition for border county patients. Residence in a border county was associated with a 1.3 percentage point decrease in the probability of being hospitalized for an ACS condition. CONCLUSIONS Increased homicide rates in Mexico were associated with increased hospitalizations for ACS conditions in the USA, although residence in a border county was associated with decreased probability of being hospitalized for an ACS condition. Expanding access in the border region may mitigate these effects by providing alternative sources of care.
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Affiliation(s)
- Kimberley Geissler
- Department of Markets, Public Policy, and Law, Boston University School of Management, Boston, MA, USA Department of Health Policy and Management, Gillings School of Global Public Health, The University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Sally C Stearns
- Department of Health Policy and Management, Gillings School of Global Public Health, The University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Charles Becker
- Department of Economics, Duke University, Durham, NC, USA
| | - Harsha Thirumurthy
- Department of Health Policy and Management, Gillings School of Global Public Health, The University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - George M Holmes
- Department of Health Policy and Management, Gillings School of Global Public Health, The University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
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Do YK, Norton EC, Stearns SC, Van Houtven CH. Informal care and caregiver's health. Health Econ 2015; 24:224-37. [PMID: 24753386 PMCID: PMC4201633 DOI: 10.1002/hec.3012] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/03/2012] [Revised: 09/23/2013] [Accepted: 10/07/2013] [Indexed: 05/15/2023]
Abstract
This study aims to measure the causal effect of informal caregiving on the health and health care use of women who are caregivers, using instrumental variables. We use data from South Korea, where daughters and daughters-in-law are the prevalent source of caregivers for frail elderly parents and parents-in-law. A key insight of our instrumental variable approach is that having a parent-in-law with functional limitations increases the probability of providing informal care to that parent-in-law, but a parent-in-law's functional limitation does not directly affect the daughter-in-law's health. We compare results for the daughter-in-law and daughter samples to check the assumption of the excludability of the instruments for the daughter sample. Our results show that providing informal care has significant adverse effects along multiple dimensions of health for daughter-in-law and daughter caregivers in South Korea.
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Affiliation(s)
- Young Kyung Do
- Department of Health Policy and Management, Seoul National University College of Medicine, and Institute of Health Policy and Management, Seoul National University Medical Research Center, Seoul, Korea
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48
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Kranz AM, Rozier RG, Preisser JS, Stearns SC, Weinberger M, Lee JY. Examining continuity of care for Medicaid-enrolled children receiving oral health services in medical offices. Matern Child Health J 2015; 19:196-203. [PMID: 24802261 PMCID: PMC4224632 DOI: 10.1007/s10995-014-1510-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [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: 11/24/2022]
Abstract
Children living in poverty encounter barriers to dentist visits and disproportionally experience dental caries. To improve access, most state Medicaid programs reimburse pediatric primary care providers for delivering preventive oral health services. To understand continuity of oral health services for children utilizing the North Carolina (NC) Into the Mouths of Babes (IMB) preventive oral health program, we examined the time to a dentist visit after a child's third birthday. This retrospective cohort study used NC Medicaid claims from 2000 to 2006 for 95,578 Medicaid-enrolled children who received oral health services before age 3. We compared children having only dentist visits before age 3 to those with: (1) only IMB visits and (2) both IMB and dentist visits. Cox proportional hazards regression was used to estimate the time to a dentist visit following a child's third birthday. Propensity scores with inverse-probability-of-treatment-weights were used to address confounding. Children with only IMB visits compared to only dentist visits before age 3 had lower rates of dentist visits after their third birthday [adjusted hazard ratio (AHR) = 0.41, 95 % confidence interval (CI) 0.39-0.43]. No difference was observed for children having both IMB and dentist visits and only dentist visits (AHR = 0.99, 95 % CI 0.96-1.03). Barriers to dental care remain as children age, hindering continuity of care for children receiving oral health services in medical offices.
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Affiliation(s)
- Ashley M Kranz
- Department of Dental Research, School of Dentistry, University of North Carolina at Chapel Hill, Koury Oral Health Sciences Building, Room 4505, Campus Box 7455, Chapel Hill, NC, 27599-7455, USA,
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49
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Kaul P, Federspiel JJ, Dai X, Stearns SC, Smith SC, Yeung M, Beyhaghi H, Zhou L, Stouffer GA. Association of inpatient vs outpatient onset of ST-elevation myocardial infarction with treatment and clinical outcomes. JAMA 2014; 312:1999-2007. [PMID: 25399275 PMCID: PMC4266685 DOI: 10.1001/jama.2014.15236] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.7] [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] [Indexed: 01/16/2023]
Abstract
IMPORTANCE Reperfusion times for ST-elevation myocardial infarction (STEMI) occurring in outpatients have improved significantly, but quality improvement efforts have largely ignored STEMI occurring in hospitalized patients (inpatient-onset STEMI). OBJECTIVE To define the incidence and variables associated with treatment and outcomes of patients who develop STEMI during hospitalization for conditions other than acute coronary syndromes (ACS). DESIGN, SETTING, AND PARTICIPANTS Retrospective observational analysis of STEMIs occurring between 2008 and 2011 as identified in the California State Inpatient Database. EXPOSURES STEMIs were classified as inpatient onset or outpatient onset based on present-on-admission codes. Patients who had a STEMI after being hospitalized for ACS were excluded from the analysis. MAIN OUTCOMES AND MEASURES Regression models were used to evaluate associations among location of onset of STEMI, resource utilization, and outcomes. Adjustments were made for patient age, sex, comorbidities, and hospital characteristics. The analysis allowed for the location of inpatient STEMI to have a multiplicative rather than an additive effect for resource utilization since these measures were highly skewed. RESULTS A total of 62,021 STEMIs were identified in 303 hospitals, of which 3068 (4.9%) occurred in patients hospitalized for non-ACS indications. Patients with inpatient-onset STEMI were older (mean, 71.5 [SD, 13.5] years vs 64.9 [SD, 14.1] years; P < .001) and more frequently female (47.4% vs 32%; P < .001) than those with outpatient-onset STEMI. Patients with inpatient-onset STEMI had higher in-hospital mortality (33.6% vs 9.2%; adjusted odds ratio (AOR), 3.05; 95% CI, 2.76-3.38; P < .001), were less likely to be discharged home (33.7% vs 69.4%; AOR, 0.38; 95% CI, 0.34-0.42; P < .001), and were less likely to undergo cardiac catheterization (33.8% vs 77.8%; AOR, 0.19; 95% CI, 0.16-0.21; P < .001) or percutaneous coronary intervention (21.6% vs 65%; AOR, 0.23; 95% CI, 0.21-0.26; P < .001). Length of stay and inpatient charges were higher for inpatient-onset STEMI (mean length of stay, 13.4 days [95% CI, 12.8-14.0 days] vs 4.7 days [95% CI, 4.6-4.8 days]; adjusted multiplicative effect, 2.51; 95% CI, 2.35-2.69; P < .001; mean inpatient charges, $245,000 [95% CI, $235,300-$254,800] vs $129,000 [95% CI, $127,900-$130,100]; adjusted multiplicative effect, 2.09; 95% CI, 1.93-2.28; P < .001). CONCLUSIONS AND RELEVANCE Patients who had a STEMI while hospitalized for a non-ACS condition, compared with those with onset of STEMI as an outpatient, were less likely to undergo invasive testing or intervention and had a higher in-hospital mortality rate.
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Affiliation(s)
- Prashant Kaul
- Division of Cardiology, University of North Carolina, Chapel Hill, NC
| | - Jerome J. Federspiel
- Department of Health Policy and Management, UNC Gillings School of Global Public Health, University of North Carolina, Chapel Hill, NC
- Sheps Center for Health Services Research, University of North Carolina, Chapel Hill, NC
| | - Xuming Dai
- Division of Cardiology, University of North Carolina, Chapel Hill, NC
| | - Sally C. Stearns
- Department of Health Policy and Management, UNC Gillings School of Global Public Health, University of North Carolina, Chapel Hill, NC
- Sheps Center for Health Services Research, University of North Carolina, Chapel Hill, NC
| | - Sidney C. Smith
- Division of Cardiology, University of North Carolina, Chapel Hill, NC
| | - Michael Yeung
- Division of Cardiology, University of North Carolina, Chapel Hill, NC
| | - Hadi Beyhaghi
- Department of Health Policy and Management, UNC Gillings School of Global Public Health, University of North Carolina, Chapel Hill, NC
| | - Lei Zhou
- Department of Health Policy and Management, UNC Gillings School of Global Public Health, University of North Carolina, Chapel Hill, NC
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50
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Bengtson LGS, Lutsey PL, Loehr LR, Kucharska-Newton A, Chen LY, Chamberlain AM, Wruck LM, Duval S, Stearns SC, Alonso A. Impact of atrial fibrillation on healthcare utilization in the community: the Atherosclerosis Risk in Communities study. J Am Heart Assoc 2014; 3:e001006. [PMID: 25359400 PMCID: PMC4338687 DOI: 10.1161/jaha.114.001006] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Background Atrial fibrillation (AF) is associated with increased risk of hospitalization. Little is known about the impact of AF on utilization of noninpatient health care or about sex or race differences in AF‐related utilization. We examined rates of inpatient and outpatient utilization by AF status in the Atherosclerosis Risk in Communities study. Methods and Results Participants with incident AF enrolled in fee‐for‐service Medicare for at least 12 continuous months between 1991 and 2009 (n=932) were matched on age, sex, race and field center with up to 3 participants without AF (n=2729). Healthcare utilization was ascertained from Medicare claims and classified by primary International Classification of Diseases, ninth revision code. The average annual numbers of days hospitalized were 13.2 (95% CI 11.6 to 15.0) and 2.8 (95% CI 2.5 to 3.1) for those with and without AF, respectively. The corresponding numbers of annual outpatient claims were 53.3 (95% CI 50.5 to 56.3) and 22.9 (95% CI 22.1 to 23.8) for those with and without AF, respectively. Most utilization among AF patients was attributable to non‐AF conditions. The adjusted rate ratio for annual days hospitalized for other cardiovascular disease–related reasons was 4.58 (95% CI: 3.41 to 6.16) for those with AF versus those without AF. The association between AF and healthcare utilization was similar among men and women and among white and black participants. Conclusions Participants with AF had considerably greater healthcare utilization, and the difference in utilization for other cardiovascular disease–related reasons was substantial. In addition to rate or rhythm treatment, AF management should focus on the accompanying cardiovascular comorbidities.
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Affiliation(s)
- Lindsay G S Bengtson
- Division of Epidemiology and Community Health, University of Minnesota, Minneapolis, MN (L.S.B., P.L.L., A.A.)
| | - Pamela L Lutsey
- Division of Epidemiology and Community Health, University of Minnesota, Minneapolis, MN (L.S.B., P.L.L., A.A.)
| | - Laura R Loehr
- Department of Epidemiology, University of North Carolina Chapel Hill, Chapel Hill, NC (L.R.L., A.K.N.)
| | - Anna Kucharska-Newton
- Department of Epidemiology, University of North Carolina Chapel Hill, Chapel Hill, NC (L.R.L., A.K.N.)
| | - Lin Y Chen
- Cardiovascular Division, Department of Medicine, University of Minnesota Medical School, Minneapolis, MN (L.Y.C., S.D.)
| | | | - Lisa M Wruck
- Department of Biostatistics, University of North Carolina Chapel Hill, Chapel Hill, NC (L.M.W.)
| | - Sue Duval
- Cardiovascular Division, Department of Medicine, University of Minnesota Medical School, Minneapolis, MN (L.Y.C., S.D.)
| | - Sally C Stearns
- Department of Health Policy and Management, University of North Carolina Chapel Hill, Chapel Hill, NC (S.C.S.)
| | - Alvaro Alonso
- Division of Epidemiology and Community Health, University of Minnesota, Minneapolis, MN (L.S.B., P.L.L., A.A.)
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