1
|
Wilson IB, Cole MB, Lee Y, Shireman TI, Justice AC, Rahman M. The relationship of age and comorbid conditions to hospital and nursing home days in Medicaid recipients with HIV. AIDS 2024; 38:993-1001. [PMID: 38411618 PMCID: PMC11062810 DOI: 10.1097/qad.0000000000003870] [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: 09/12/2023] [Revised: 01/30/2024] [Accepted: 02/12/2024] [Indexed: 02/28/2024]
Abstract
OBJECTIVE To determine how aging impacts healthcare utilization in persons with HIV (PWH) compared with persons without HIV (PWoH). DESIGN Matched case-control study. METHODS We studied Medicaid recipients in the United States, aged 18-64 years, from 2001 to 2012. We matched each of 270 074 PWH to three PWoH by baseline year, age, gender, and zip code. Outcomes were hospital and nursing home days per month (DPM). Comorbid condition groups were cardiovascular disease, diabetes, liver disease, mental health conditions, pulmonary disease, and renal disease. We used linear regression to examine the joint relationships of age and comorbid conditions on the two outcomes, stratified by sex at birth. RESULTS We found small excesses in hospital DPM for PWH compared with PWoH. There were 0.03 and 0.07 extra hospital DPM for female and male individuals, respectively, and no increases with age. In contrast, excess nursing home DPM for PWH compared with PWoH rose linearly with age, peaking at 0.35 extra days for female individuals and 0.4 extra days for male individuals. HIV-associated excess nursing home DPM were greatest for persons with cardiovascular disease, diabetes, mental health conditions, and renal disease. For PWH at age 55 years, this represents an 81% increase in the nursing home DPM for male individuals, and a 110% increase for female individuals, compared PWoH. CONCLUSION Efforts to understand and interrupt this pronounced excess pattern of nursing home DPM among PWH compared with PWoH are needed and may new insights into how HIV and comorbid conditions jointly impact aging with HIV.
Collapse
Affiliation(s)
- Ira B. Wilson
- Department of Health Services, Policy & Practice, Brown University School of Public Health, Providence, RI
| | - Megan B. Cole
- Department of Health Law, Policy, & Management, Boston University School of Public Health, Boston, MA
| | - Yoojin Lee
- Department of Health Services, Policy & Practice, Brown University School of Public Health, Providence, RI
| | - Theresa I. Shireman
- Department of Health Services, Policy & Practice, Brown University School of Public Health, Providence, RI
| | - Amy C. Justice
- Schools of Medicine and Public Health, Yale University; Veterans Affairs Connecticut Healthcare System, New Haven, CT, USA
| | - Momotazur Rahman
- Department of Health Services, Policy & Practice, Brown University School of Public Health, Providence, RI
| |
Collapse
|
2
|
Babbs G, Hughto JMW, Shireman TI, Meyers DJ. Emergency Department Use Disparities Among Transgender and Cisgender Medicare Beneficiaries, 2011-2020. JAMA Intern Med 2024; 184:443-445. [PMID: 38345803 PMCID: PMC10862265 DOI: 10.1001/jamainternmed.2023.8209] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2023] [Accepted: 12/04/2023] [Indexed: 02/15/2024]
Abstract
This cross-sectional study compares emergency department use among transgender and gender-diverse as well as cisgender Medicare beneficiaries.
Collapse
Affiliation(s)
- Gray Babbs
- Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, Rhode Island
- Center for Gerontology & Healthcare Research, Brown University School of Public Health, Providence, Rhode Island
| | - Jaclyn M. W. Hughto
- Department of Behavioral and Social Sciences, Brown University School of Public Health, Providence, Rhode Island
- Department of Epidemiology, Brown University School of Public Health, Providence, Rhode Island
- Center for Health Promotion and Health Equity, Brown University School of Public Health, Providence, Rhode Island
| | - Theresa I. Shireman
- Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, Rhode Island
- Center for Gerontology & Healthcare Research, Brown University School of Public Health, Providence, Rhode Island
| | - David J. Meyers
- Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, Rhode Island
- Center for Gerontology & Healthcare Research, Brown University School of Public Health, Providence, Rhode Island
| |
Collapse
|
3
|
Hughto JM, Varma H, Yee K, Babbs G, Hughes LD, Pletta DR, Meyers DJ, Shireman TI. Characterizing Disparities in the HIV Care Continuum among Transgender and Cisgender Medicare Beneficiaries. medRxiv 2024:2024.03.19.24304525. [PMID: 38562705 PMCID: PMC10984057 DOI: 10.1101/2024.03.19.24304525] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 04/04/2024]
Abstract
Background In the US, transgender and gender-diverse (TGD) individuals, particularly trans feminine individuals, experience a disproportionately high burden of HIV relative to their cisgender counterparts. While engagement in the HIV Care Continuum (e.g., HIV care visits, antiretroviral (ART) prescribed, ART adherence) is essential to reduce viral load, HIV transmission, and related morbidity, the extent to which TGD people engage in one or more steps of the HIV Care Continuum at similar levels as cisgender people is understudied on a national level and by gendered subgroups. Methods and Findings We used Medicare Fee-for-Service claims data from 2009 to 2017 to identify TGD (trans feminine and non-binary (TFN), trans masculine and non-binary (TMN), unclassified gender) and cisgender (male, female) beneficiaries with HIV. Using a retrospective cross-sectional design, we explored within- and between-gender group differences in the predicted probability (PP) of engaging in one or more steps of the HIV Care Continuum. TGD individuals had a higher predicted probability of every HIV Care Continuum outcome compared to cisgender individuals [HIV Care Visits: TGD PP=0.22, 95% Confidence Intervals (CI)=0.22-0.24; cisgender PP=0.21, 95% CI=0.21-0.22); Sexually Transmitted Infection (STI) Screening (TGD PP=0.12, 95% CI=0.11-0.12; cisgender PP=0.09, 95% CI=0.09-0.10); ART Prescribed (TGD PP=0.61, 95% CI=0.59-0.63; cisgender PP=0.52, 95% CI=0.52-0.54); and ART Persistence or adherence (90% persistence: TGD PP=0.27, 95% CI=0.25-0.28; 95% persistence: TGD PP=0.13, 95% CI=0.12-0.14; 90% persistence: cisgender PP=0.23, 95% CI=0.22-0.23; 95% persistence: cisgender PP=0.11, 95% CI=0.11-0.12)]. Notably, TFN individuals had the highest probability of every outcome (HIV Care Visits PP =0.25, 95% CI=0.24-0.27; STI Screening PP =0.22, 95% CI=0.21-0.24; ART Prescribed PP=0.71, 95% CI=0.69-0.74; 90% ART Persistence PP=0.30, 95% CI=0.28-0.32; 95% ART Persistence PP=0.15, 95% CI=0.14-0.16) and TMN people or cisgender females had the lowest probability of every outcome (HIV Care Visits: TMN PP =0.18, 95% CI=0.14-0.22; STI Screening: Cisgender Female PP =0.11, 95% CI=0.11-0.12; ART Receipt: Cisgender Female PP=0.40, 95% CI=0.39-0.42; 90% ART Persistence: TMN PP=0.15, 95% CI=0.11-0.20; 95% ART Persistence: TMN PP=0.07, 95% CI=0.04-0.10). The main limitation of this research is that TGD and cisgender beneficiaries were included based on their observed care, whereas individuals who did not access relevant care through Fee-for-Service Medicare at any point during the study period were not included. Thus, our findings may not be generalizable to all TGD and cisgender individuals with HIV, including those with Medicare Advantage or other types of insurance. Conclusions Although TGD beneficiaries living with HIV had superior engagement in the HIV Care Continuum than cisgender individuals, findings highlight notable disparities in engagement for TMN individuals and cisgender females, and engagement was still low for all Medicare beneficiaries, independent of gender. Interventions are needed to reduce barriers to HIV care engagement for all Medicare beneficiaries to improve treatment outcomes and reduce HIV-related morbidity and mortality in the US.
Collapse
Affiliation(s)
- Jaclyn M.W. Hughto
- Departments of Behavioral and Social Sciences and Epidemiology, Brown University School of Public Health, Providence, RI, United States
- Center for Health Promotion and Health Equity, Brown University School of Public Health, Providence, RI, United States
- The Fenway Institute, Fenway Health, Boston, MA, United States
| | - Hiren Varma
- Center for Gerontology & Healthcare Research, Brown University School of Public Health, Providence, RI, United States
- Department of Health Services Policy & Practice, Brown University School of Public Health, Providence, RI, United States
| | - Kim Yee
- OHSU-PSU School of Public Health, Portland, OR, United States
| | - Gray Babbs
- Center for Gerontology & Healthcare Research, Brown University School of Public Health, Providence, RI, United States
- Department of Health Services Policy & Practice, Brown University School of Public Health, Providence, RI, United States
| | - Landon D. Hughes
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA, United States
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, MA, United States
| | - David R. Pletta
- Center for Health Promotion and Health Equity, Brown University School of Public Health, Providence, RI, United States
| | - David J. Meyers
- Center for Gerontology & Healthcare Research, Brown University School of Public Health, Providence, RI, United States
- Department of Health Services Policy & Practice, Brown University School of Public Health, Providence, RI, United States
| | - Theresa I. Shireman
- Center for Gerontology & Healthcare Research, Brown University School of Public Health, Providence, RI, United States
- Department of Health Services Policy & Practice, Brown University School of Public Health, Providence, RI, United States
| |
Collapse
|
4
|
Moyo P, Merlin JS, George M, Shireman TI, Marshall BD. Association of Opioid Use Disorder Diagnosis With Use of Physical Therapy and Chiropractic Care Among Chronic Low Back Pain Patients: A Group-Based Trajectory Analysis. J Pain 2024; 25:742-754. [PMID: 37820847 PMCID: PMC10922407 DOI: 10.1016/j.jpain.2023.10.003] [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] [Subscribe] [Scholar Register] [Received: 06/07/2023] [Revised: 10/05/2023] [Accepted: 10/06/2023] [Indexed: 10/13/2023]
Abstract
Nonpharmacologic approaches are recommended as first-line treatment for chronic pain, and their importance is heightened among individuals with co-occurring opioid use disorder (OUD), in whom opioid therapies may be particularly detrimental. Our objectives were to assess the receipt and trajectories of nonpharmacologic pain treatment and determine the association of OUD diagnosis with these trajectories. This retrospective cohort study used Medicare claims data from 2016 to 2018 and applied group-based trajectory models to identify distinct patterns of physical therapy (PT) or chiropractic care treatment over the 12 months following a new episode of chronic low back pain. We used logistic regression models to estimate the association of co-occurring OUD with group membership in PT and chiropractic trajectories. Our sample comprised 607,729 beneficiaries at least 18 years of age, of whom 11.4% had a diagnosis of OUD. The 12-month prevalence of PT and chiropractic treatment receipt was 24.7% and 27.1%, respectively, and lower among Medicare beneficiaries with co-occurring OUD (PT: 14.6%; chiropractic: 6.8%). The final models identified 3 distinct trajectories each for PT (no/little use [76.6% of sample], delayed and increasing use [8.2%], and early and declining use [15.2%]); and chiropractic (no/little use [75.0% of sample], early and declining use [17.3%], and early and sustained use [7.7%]). People with OUD were more likely to belong in trajectories with little/no PT or chiropractic care as compared to other trajectories. The findings indicate that people with co-occurring chronic pain and OUD often do not receive early or any nonpharmacologic pain therapies as recommended by practice guidelines. PERSPECTIVE: PT and chiropractic care use were low overall and even lower among Medicare beneficiaries with co-occurring OUD compared with those without OUD. As updated guidelines on pain management are promulgated, targeted interventions (eg, insurance policy, provider, and patient education) are needed to ensure equitable access to guideline-recommended pain therapies.
Collapse
Affiliation(s)
- Patience Moyo
- Brown University School of Public Health, Department of Health Services, Policy, and Practice, Providence, RI, USA
| | - Jessica S. Merlin
- Challenges in Managing and Preventing Pain Clinical Research Center, Division of General Internal Medicine, University of Pittsburgh, PA, USA
| | - Miriam George
- Brown University School of Public Health, Department of Health Services, Policy, and Practice, Providence, RI, USA
| | - Theresa I. Shireman
- Brown University School of Public Health, Department of Health Services, Policy, and Practice, Providence, RI, USA
| | - Brandon D.L. Marshall
- Brown University School of Public Health, Department of Epidemiology, Providence, RI, USA
| |
Collapse
|
5
|
Ellison J, Pudasainy S, Bellerose M, Quinn D, Borrero S, Olson I, Chen Q, Shireman TI, Jarlenski MP. Contraceptive Use Among Traditional Medicare And Medicare Advantage Enrollees. Health Aff (Millwood) 2024; 43:98-107. [PMID: 38190592 DOI: 10.1377/hlthaff.2023.00286] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2024]
Abstract
Medicare is the primary source of health insurance coverage for reproductive-age people with Social Security Disability Insurance. However, Medicare does not require contraceptive coverage for pregnancy prevention, and little is known about contraceptive use in traditional Medicare and Medicare Advantage. We analyzed Medicare and Optum data to assess variations in contraceptive use and methods used by traditional Medicare and Medicare Advantage enrollees, as well as among enrollees with and without noncontraceptive clinical indications. Clinically indicated contraceptives are used for reasons other than pregnancy prevention, including menstrual regulation or to treat acne, menorrhagia, and endometriosis. Contraceptive use was higher among Medicare Advantage enrollees than traditional Medicare enrollees, but use in both populations was low compared with contraceptive use among Medicaid enrollees. We found significant variation by Medicare type with respect to contraceptive methods used. Relative to traditional Medicare, the probability of long-acting reversible contraception was more than three times higher in Medicare Advantage, and the probability of tubal sterilization was more than ten times higher. Overall, Medicare enrollees with noncontraceptive clinical indications had twice the probability of contraceptive use as those without them. Medicare coverage of all contraceptive methods without cost sharing would help address financial barriers to contraceptives and support the reproductive autonomy of disabled enrollees.
Collapse
|
6
|
Lane CY, Lo D, Thoma LM, Zhang T, Varma H, Dalal DS, Baker TA, Shireman TI. Sociocultural and Economic Disparities in Physical Therapy Utilization Among Insured Older Adults With Rheumatoid Arthritis. J Rheumatol 2023; 50:1414-1421. [PMID: 37527853 DOI: 10.3899/jrheum.2023-0103] [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] [Accepted: 05/31/2023] [Indexed: 08/03/2023]
Abstract
OBJECTIVE To examine influences of sociocultural and economic determinants on physical therapy (PT) utilization for older adults with rheumatoid arthritis (RA). METHODS In these annual cross-sectional analyses between 2012 and 2016, we accessed Medicare enrollment data and fee-for-service claims. The cohort included Medicare beneficiaries with RA based on 3 diagnosis codes or 2 codes plus a disease-modifying antirheumatic drug medication claim. We defined race and ethnicity and dual Medicare/Medicaid coverage (proxy for income) using enrollment data. Adults with a Current Procedural Terminology code for PT evaluation were classified as utilizing PT services. Associations between race and ethnicity and dual coverage and PT utilization were estimated with logistic regression analyses. Potential interactions between race and ethnicity status and dual coverage were tested using interaction terms. RESULTS Of 106,470 adults with RA (75.1% female; aged 75.8 [SD 7.3] years; 83.9% identified as non-Hispanic White, 8.8% as non-Hispanic Black, 7.2% as Hispanic), 9.6-12.5% used PT in a given year. Non-Hispanic Black (adjusted odds ratio [aOR] 0.77, 95% CI 0.73-0.82) and Hispanic (aOR 0.92, 95% CI 0.87-0.98) individuals had lower odds of PT utilization than non-Hispanic White individuals. Adults with dual coverage (lower income) had lower odds of utilization than adults with Medicare only (aOR 0.44, 95% CI 0.43-0.46). There were no significant interactions between race and ethnicity status and dual coverage on utilization. CONCLUSION We found sociocultural and economic disparities in PT utilization in older adults with RA. We must identify and address the underlying factors that influence these disparities in order to mitigate them.
Collapse
Affiliation(s)
- Chris Y Lane
- C.Y. Lane, PT, DPT, L.M. Thoma, PT, DPT, PhD, Department of Health Sciences, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina;
| | - Derrick Lo
- D. Lo, ScM, T. Zhang, MD, PhD, H. Varma, MS, D.S. Dalal, MD, MPH, T.I. Shireman, PhD, Department of Health Services, Policy and Practices, Brown University School of Public Health, Providence, Rhode Island
| | - Louise M Thoma
- C.Y. Lane, PT, DPT, L.M. Thoma, PT, DPT, PhD, Department of Health Sciences, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Tingting Zhang
- D. Lo, ScM, T. Zhang, MD, PhD, H. Varma, MS, D.S. Dalal, MD, MPH, T.I. Shireman, PhD, Department of Health Services, Policy and Practices, Brown University School of Public Health, Providence, Rhode Island
| | - Hiren Varma
- D. Lo, ScM, T. Zhang, MD, PhD, H. Varma, MS, D.S. Dalal, MD, MPH, T.I. Shireman, PhD, Department of Health Services, Policy and Practices, Brown University School of Public Health, Providence, Rhode Island
| | - Deepan S Dalal
- D. Lo, ScM, T. Zhang, MD, PhD, H. Varma, MS, D.S. Dalal, MD, MPH, T.I. Shireman, PhD, Department of Health Services, Policy and Practices, Brown University School of Public Health, Providence, Rhode Island
| | - Tamara A Baker
- T.A. Baker, PhD, Department of Psychiatry, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Theresa I Shireman
- D. Lo, ScM, T. Zhang, MD, PhD, H. Varma, MS, D.S. Dalal, MD, MPH, T.I. Shireman, PhD, Department of Health Services, Policy and Practices, Brown University School of Public Health, Providence, Rhode Island
| |
Collapse
|
7
|
Bhondoekhan F, Marshall BDL, Shireman TI, Trivedi AN, Merlin JS, Moyo P. Racial and Ethnic Differences in Receipt of Nonpharmacologic Care for Chronic Low Back Pain Among Medicare Beneficiaries With OUD. JAMA Netw Open 2023; 6:e2333251. [PMID: 37698860 PMCID: PMC10498328 DOI: 10.1001/jamanetworkopen.2023.33251] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2023] [Accepted: 08/03/2023] [Indexed: 09/13/2023] Open
Abstract
Importance Nonpharmacologic treatments are important for managing chronic pain among persons with opioid use disorder (OUD), for whom opioid and other pharmacologic therapies may be particularly harmful. Racial and ethnic minority individuals with chronic pain and OUD are vulnerable to suboptimal pain management due to systemic inequities and structural racism, highlighting the need to understand their receipt of guideline-recommended nonpharmacologic pain therapies, including physical therapy (PT) and chiropractic care. Objective To assess differences across racial and ethnic groups in receipt of PT or chiropractic care for chronic low back pain (CLBP) among persons with comorbid OUD. Design, Setting, and Participants This retrospective cohort study used a 20% random sample of national Medicare administrative data from January 1, 2016, to December 31, 2018, to identify fee-for-service community-dwelling beneficiaries with a new episode of CLBP and comorbid OUD. Data were analyzed from March 1, 2022, to July 30, 2023. Exposures Race and ethnicity as a social construct, categorized as American Indian or Alaska Native, Asian or Pacific Islander, Black or African American, Hispanic, non-Hispanic White, and unknown or other. Main Outcomes and Measures The main outcomes were receipt of PT or chiropractic care within 3 months of CLBP diagnosis. The time (in days) to receiving these treatments was also assessed. Results Among 69 362 Medicare beneficiaries analyzed, the median age was 60.0 years (IQR, 51.5-68.7 years) and 42 042 (60.6%) were female. A total of 745 beneficiaries (1.1%) were American Indian or Alaska Native; 444 (0.6%), Asian or Pacific Islander; 9822 (14.2%), Black or African American; 4124 (5.9%), Hispanic; 53 377 (77.0%); non-Hispanic White; and 850 (1.2%), other or unknown race. Of all beneficiaries, 7104 (10.2%) received any PT or chiropractic care 3 months after a new CLBP episode. After adjustment, Black or African American (adjusted odds ratio, 0.46; 95% CI, 0.39-0.55) and Hispanic (adjusted odds ratio, 0.54; 95% CI, 0.43-0.67) persons had lower odds of receiving chiropractic care within 3 months of CLBP diagnosis compared with non-Hispanic White persons. Median time to chiropractic care was longest for American Indian or Alaska Native (median, 8.5 days [IQR, 0-44.0 days]) and Black or African American (median, 7.0 days [IQR, 0-42.0 days]) persons and shortest for Asian or Pacific Islander persons (median, 0 days [IQR, 0-6.0 days]). No significant racial and ethnic differences were observed for PT. Conclusions and Relevance In this retrospective cohort study of Medicare beneficiaries with comorbid CLBP and OUD, receipt of PT and chiropractic care was low overall and lower across most racial and ethnic minority groups compared with non-Hispanic White persons. The findings underscore the need to address inequities in guideline-concordant pain management, particularly among Black or African American and Hispanic persons with OUD.
Collapse
Affiliation(s)
- Fiona Bhondoekhan
- Department of Epidemiology, Brown University School of Public Health, Providence, Rhode Island
| | - Brandon D. L. Marshall
- Department of Epidemiology, Brown University School of Public Health, Providence, Rhode Island
| | - Theresa I. Shireman
- Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, Rhode Island
| | - Amal N. Trivedi
- Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, Rhode Island
| | - Jessica S. Merlin
- CHAllenges in Managing and Preventing Pain Clinical Research Center, Division of General Internal Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Patience Moyo
- Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, Rhode Island
| |
Collapse
|
8
|
Shireman TI, Fashaw-Walters S, Zhang T, Zullo AR, Gerlach LB, Coe AB, Daiello L, Lo D, Strominger J, Bynum JPW. Federal Nursing Home Policies on Antipsychotics had Similar Impacts by Race and Ethnicity for Residents With Dementia. J Am Med Dir Assoc 2023; 24:1283-1289.e4. [PMID: 37127131 PMCID: PMC10523862 DOI: 10.1016/j.jamda.2023.03.027] [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: 10/21/2022] [Revised: 02/15/2023] [Accepted: 03/20/2023] [Indexed: 05/03/2023]
Abstract
OBJECTIVES Federal initiatives have been successful in reducing antipsychotic exposure in nursing home residents with dementia. We assessed if these initiatives were implemented equally across racial and ethnic minority groups. DESIGN Retrospective, cross-sectional trends study. SETTING AND PARTICIPANTS National long-stay nursing home residents with dementia from 2011 to 2017. METHODS We examined trends in psychotropic drug class exposures from the Minimum Data Set assessments for non-Hispanic Black (NHB), Hispanic, and non-Hispanic White (NHW) residents using interrupted time-series analyses with age-sex standardized quarterly outcomes and time points to denote the National Partnership (2012) and Five Star Rating changes (2015). RESULTS Initially, antipsychotic (33.0%) and sedative (6.8%) exposure was highest for Hispanic residents; antidepressant (59.8%) and anxiolytic (23.4%) exposure was highest for NHW residents; NHB residents had the lowest use of each. Antipsychotic use dropped at the time of the Partnership (β = -0.8807, P = .0023) and the slope declined further after the Partnership (β = -0.6611, P < .0001) for NHW. In comparison to NHW, the level and slope changes for NHB and Hispanics were not significantly different. The Five Star Rating change did not impact the level of antipsychotic use (β = 0.027, P = .9467), but the slope changed to indicate a slowed rate of decline (β = 0.1317, P = .4075) for NHW. As to the other psychotropic drug classes, there were few significant differences between trends seen in the racial and ethnic subgroups. The following exceptions were noted: antidepressant use decreased at a faster rate for NHB residents post-Partnership (β = -0.1485, P = .0371), and after the Five Star Rating change, NHB residents (β = -0.0428, P = .0312) and Hispanic residents (β = -0.0834, P < .0001) saw antidepressant use decrease faster than NHW. Sedative use in slope post-Partnership period (β = -0.086, P = .0275) and post-Five Star Rating (β = -0.0775, P < .0001) declined faster among Hispanic residents. CONCLUSIONS AND IMPLICATIONS We found little evidence of clinically meaningful differences in changes to 4 classes of psychotropic medication use among racial and ethnic minority nursing home residents with dementia following 2 major federal initiatives.
Collapse
Affiliation(s)
- Theresa I Shireman
- Center for Gerontology and Healthcare Research, Brown University School of Public Health, Providence, RI, USA; Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, RI, USA.
| | - Shekinah Fashaw-Walters
- Division of Health Policy and Management, University of Minnesota School of Public Health, Minneapolis, MN, USA
| | - Tingting Zhang
- Center for Gerontology and Healthcare Research, Brown University School of Public Health, Providence, RI, USA; Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, RI, USA
| | - Andrew R Zullo
- Center for Gerontology and Healthcare Research, Brown University School of Public Health, Providence, RI, USA; Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, RI, USA; Department of Epidemiology, Brown University School of Public Health, Providence, RI, USA; Center of Innovation in Long-Term Services and Supports, Providence Veterans Affairs Medical Center, Providence, RI, USA
| | - Lauren B Gerlach
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, USA; Department of Psychiatry, University of Michigan, Ann Arbor, MI, USA
| | - Antoinette B Coe
- Department of Clinical Pharmacy, College of Pharmacy, University of Michigan, Ann Arbor, MI, USA
| | - Lori Daiello
- Center for Gerontology and Healthcare Research, Brown University School of Public Health, Providence, RI, USA; Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, RI, USA; Department of Neurology, Warren Alpert Medical School, Brown University, Providence, RI, USA
| | - Derrick Lo
- Center for Gerontology and Healthcare Research, Brown University School of Public Health, Providence, RI, USA
| | - Julie Strominger
- Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI, USA
| | - Julie P W Bynum
- Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA
| |
Collapse
|
9
|
Choudry E, Rofé KL, Konnyu K, Marshall BDL, Shireman TI, Merlin JS, Trivedi AN, Schmidt C, Bhondoekhan F, Moyo P. Treatment Patterns and Population Characteristics of Nonpharmacological Management of Chronic Pain in the United States' Medicare Population: A Scoping Review. Innov Aging 2023; 7:igad085. [PMID: 38094932 PMCID: PMC10714895 DOI: 10.1093/geroni/igad085] [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] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2023] [Indexed: 02/01/2024] Open
Abstract
Background and Objectives Clinical practice guidelines recommend noninvasive nonpharmacological pain therapies; however, reviews that assess the literature pertaining to nonpharmacological pain management among older adults and people with long-term disabilities who are disproportionately affected by pain are lacking. This scoping review aimed to systematically map and characterize the existing studies about the receipt of noninvasive, nonpharmacological pain therapies by Medicare beneficiaries. Research Design and Methods We conducted a literature search in MEDLINE (PubMed), CINAHL (EBSCO), SocINDEX (EBSCO), Cochrane Library, Web of Science citation indices, and various sources of gray literature. The initial search was conducted on November 2, 2021, and updated on March 9, 2022. Two independent reviewers screened titles, abstracts, and full texts for inclusion and extracted the characteristics of the studies, studied populations, and nonpharmacological pain therapies. Data were summarized using tabular and narrative formats. Results The final review included 33 studies. Of these, 24 were quantitative, 7 were qualitative, and 2 were mixed-methods studies. Of 32 studies that focused on Medicare beneficiaries, 10 did not specify the Medicare type, and all but one of the remaining studies were restricted to fee-for-service enrollees. Back and neck pain and arthritis were the most commonly studied pain types. Chiropractic care (n = 19) and physical therapy (n = 17) appeared frequently among included studies. The frequency and/or duration of nonpharmacological treatment were mentioned in 13 studies. Trends in the utilization of nonpharmacological pain therapies were assessed in 6 studies but none of these studies went beyond 2008. Discussion and Implications This scoping review found that manipulative therapies, mainly chiropractic, have been the most widely studied approaches for nonpharmacological pain management in the Medicare population. The review also identified the need for future research that updates trend data and addresses contemporary issues such as rising Medicare Advantage enrollment and promulgation of practice guidelines for pain management.
Collapse
Affiliation(s)
- Erum Choudry
- School of Public Health, Brown University, Providence, Rhode Island, USA
| | - Kara L Rofé
- School of Public Health, Brown University, Providence, Rhode Island, USA
| | - Kristin Konnyu
- Center for Evidence Synthesis in Health, Department of Health Services, Policy and Practice, School of Public Health, Brown University, Providence, Rhode Island, USA
| | - Brandon D L Marshall
- Department of Epidemiology, School of Public Health, Brown University, Providence, Rhode Island, USA
| | - Theresa I Shireman
- Center for Gerontology and Healthcare Research, Department of Health Services, Policy and Practice, School of Public Health, Brown University, Providence, Rhode Island, USA
| | - Jessica S Merlin
- Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
- Division of Infectious Disease, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Amal N Trivedi
- Center for Gerontology and Healthcare Research, Department of Health Services, Policy and Practice, School of Public Health, Brown University, Providence, Rhode Island, USA
- Department of Medicine, Brown University, Providence, Rhode Island, USA
| | - Catherine Schmidt
- Department of Physical Therapy, Massachusetts General Hospital Institute of Health Professions, School of Health and Rehabilitation Sciences, Boston, Massachusetts, USA
| | - Fiona Bhondoekhan
- Department of Epidemiology, School of Public Health, Brown University, Providence, Rhode Island, USA
| | - Patience Moyo
- Center for Gerontology and Healthcare Research, Department of Health Services, Policy and Practice, School of Public Health, Brown University, Providence, Rhode Island, USA
| |
Collapse
|
10
|
Ryskina K, Lo D, Zhang T, Gerlach L, Bynum J, Shireman TI. Potentially Harmful Medication Prescribing by the Degree of Physician Specialization in Nursing Home Practice: An Observational Study. J Am Med Dir Assoc 2023; 24:1240-1246.e2. [PMID: 37088104 PMCID: PMC10524654 DOI: 10.1016/j.jamda.2023.03.017] [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: 10/27/2022] [Revised: 02/14/2023] [Accepted: 03/12/2023] [Indexed: 04/25/2023]
Abstract
OBJECTIVES The use of anticholinergics, antipsychotics, benzodiazepines, and other potentially harmful medications (PHMs) is associated with particularly poor outcomes in nursing home (NH) residents with Alzheimer's disease and related dementias (ADRD). Our objective was to compare PHM prescribing by NH physicians and advanced practitioners who focus their practice on NH residents (NH specialists) vs non-NH specialists. DESIGN Retrospective cohort study. SETTING AND PARTICIPANTS We included a 20% random sample of Medicare beneficiaries with ADRD who resided in 12,278 US NHs in 2017. Long-stay NH residents with ADRD were identified using MDS, Medicare Parts A and B claims. Residents <65 years old or without continuous Part D coverage were excluded. METHODS Physicians in generalist specialties and advanced practitioners with ≥90% of Part B claims for NH care were considered NH specialists. Residents were assigned to NH specialists vs non-NH specialists based on plurality of Part D claims submitted for that resident. Any PHM use (defined using the Beers Criteria) and the proportion of NH days on a PHM were modeled using generalized estimating equations. Models included resident demographics, clinical characteristics, cognitive and functional status, behavioral assessments, and facility characteristics. RESULTS Of the 54,713 residents in the sample, 27.9% were managed by an NH specialist and 72.1% by a non-NH specialist. There was no statistically significant difference in any PHM use [odds ratio (OR) 0.97, 95% CI 0.93-1.02, P = .23]. There were lower odds of prolonged PHM use (OR 0.87, 95% CI 0.81-0.94, P < .001, for PHM use on >75% vs >0%-<25% of NH days) for NH specialists vs non-NH specialists. CONCLUSIONS AND IMPLICATIONS Although the use of PHMs among NH residents with ADRD managed by NH specialists was not lower, they were less likely to receive PHMs over longer periods of time. Future work should evaluate the underlying causes of these differences to inform interventions to improve prescribing for NH residents.
Collapse
Affiliation(s)
- Kira Ryskina
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA.
| | - Derrick Lo
- Center for Gerontology & Healthcare Research, Brown University School of Public Health, Providence, RI, USA
| | - Tingting Zhang
- Center for Gerontology & Healthcare Research, Brown University School of Public Health, Providence, RI, USA
| | - Lauren Gerlach
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, USA
| | - Julie Bynum
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, USA; Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Theresa I Shireman
- Center for Gerontology & Healthcare Research, Brown University School of Public Health, Providence, RI, USA
| |
Collapse
|
11
|
Moyo P, Vaillant J, Girard A, Gairola R, Shireman TI, Trivedi AN, Merlin JS, Marshall BDL. Prevalence of opioid and nonopioid pain management therapies among Medicare beneficiaries with musculoskeletal pain conditions from 2016 to 2019. Drug Alcohol Depend 2023; 248:109930. [PMID: 37269776 DOI: 10.1016/j.drugalcdep.2023.109930] [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: 02/14/2023] [Revised: 05/11/2023] [Accepted: 05/13/2023] [Indexed: 06/05/2023]
Abstract
INTRODUCTION Pain treatment guidelines prioritize nonopioid therapies over opioid medications to prevent opioid-related harms. We examined trends in receipt and intensity of nonpharmacologic, nonopioid medication, and opioid therapies among Medicare beneficiaries. METHODS Using a 20% national random sample of Medicare data from 2016 to 2019, we identified fee-for-service beneficiaries with ≥2 diagnoses of back, neck, fibromyalgia, or osteoarthritis/joint pain annually. We excluded beneficiaries with cancer. We calculated annual proportions of beneficiaries who received physical therapy (PT), chiropractic care, gabapentin, and opioids, overall and in demographic, geographic, and clinical subgroups. We estimated the intensity of therapies using the annual number of visitsor prescription fills, prescription days' supply, and opioid dose. RESULTS During 2016-2019, PT receipt increased (22.8% to 25.5%) and the mean number of visits among recipients of PT went from 12 to 13. Chiropractic receipt (~18%) and mean annual visits (~10) remained unchanged. The prevalence of gabapentin receipt was stable at ~22% and the mean annual number of fills was unchanged though gabapentin days increased slightly. Opioid prescribing decreased (56.7% to 46.5%) and reductions in opioid dose and duration were observed. Opioid receipt was high among beneficiaries who were under 65 years, American Indian/Alaska Native, Black/African American, or had opioid use disorder (OUD), in whom nonpharmacologic therapies were also received the least. CONCLUSION Utilization of nonopioid therapies lagged opioids among Medicare beneficiaries with musculoskeletal pain, with limited changes from 2016 to 2019. As opioid prescribing declines and alternative pain therapy receipt remains low, there are potential increasing risks of pain going untreated or undertreated and individuals seeking illicit opioids to alleviate their pain.
Collapse
Affiliation(s)
- Patience Moyo
- Brown University School of Public Health, Department of Health Services, Policy, and Practice, Providence, RI, USA.
| | | | - Anthony Girard
- Brown University School of Public Health, Department of Biostatistics, Providence, RI, USA
| | - Richa Gairola
- Brown University School of Public Health, Department of Epidemiology, Providence, RI, USA
| | - Theresa I Shireman
- Brown University School of Public Health, Department of Health Services, Policy, and Practice, Providence, RI, USA
| | - Amal N Trivedi
- Brown University School of Public Health, Department of Health Services, Policy, and Practice, Providence, RI, USA
| | - Jessica S Merlin
- CHAllenges in Managing and Preventing Pain (CHAMPP) Clinical Research Center, Division of General Internal Medicine, University of Pittsburgh, PA, USA
| | - Brandon D L Marshall
- Brown University School of Public Health, Department of Epidemiology, Providence, RI, USA
| |
Collapse
|
12
|
Zhang T, Thomas KS, Zullo AR, Coe AB, Gerlach LB, Daiello LA, Varma H, Lo D, Joshi R, Bynum JPW, Shireman TI. State Variation in Antipsychotic Use Among Assisted Living Residents With Dementia. J Am Med Dir Assoc 2023; 24:555-558.e1. [PMID: 36841263 PMCID: PMC10089770 DOI: 10.1016/j.jamda.2023.01.014] [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: 09/27/2022] [Revised: 12/19/2022] [Accepted: 01/18/2023] [Indexed: 02/25/2023]
Abstract
OBJECTIVES More than two-thirds of assisted living (AL) residents have dementia or cognitive impairment and antipsychotics are commonly prescribed for behavioral disturbances. As AL communities are regulated by state-level policies, which vary significantly regarding the care for people with dementia, we examined how antipsychotic prescribing varied across states among AL residents with dementia. DESIGN This was an observational study using 20% sample of national Medicare data in 2017. SETTING AND PARTICIPANTS The study cohort included Medicare beneficiaries with dementia aged 65 years or older who resided in larger (≥25-bed) ALs in 2017. METHODS The study outcome was the percentage of eligible AL person-months in which antipsychotics were prescribed for each state. We used a random intercept linear regression model to shrink estimates toward the overall mean use of antipsychotics addressing unstable estimates due to small sample sizes in some states. RESULTS A total of 20,867 AL residents with dementia were included in the analysis, contributing to 194,718 person-months of observation. On average, AL residents with dementia were prescribed antipsychotics during 12.6% of their person-months. This rate varied significantly by state, with a low of 7.8% (95% CI 5.9%-10.3%) for Hawaii to a high of 20.5% (95% CI 16.4%-25.3%) for Wyoming. CONCLUSIONS AND IMPLICATIONS We observed significant state variation in the prescribing of antipsychotics among AL residents with dementia using national data. These variations may reflect differences in state regulations regarding the care for AL residents with dementia and suggest the need for further investigation to ensure high quality of care.
Collapse
Affiliation(s)
- Tingting Zhang
- Center for Gerontology and Healthcare Research, Brown University School of Public Health, Providence, RI, USA; Department of Health Services, Policy & Practice, Brown University School of Public Health, Providence, RI, USA.
| | - Kali S Thomas
- Center for Gerontology and Healthcare Research, Brown University School of Public Health, Providence, RI, USA; Department of Health Services, Policy & Practice, Brown University School of Public Health, Providence, RI, USA; Center of Innovation in Long-Term Services and Supports, Providence Veterans Affairs Medical Center, Providence, RI, USA
| | - Andrew R Zullo
- Center for Gerontology and Healthcare Research, Brown University School of Public Health, Providence, RI, USA; Department of Health Services, Policy & Practice, Brown University School of Public Health, Providence, RI, USA; Department of Epidemiology, Brown University School of Public Health, Providence, RI, USA
| | - Antoinette B Coe
- Department of Clinical Pharmacy, College of Pharmacy, University of Michigan, Ann Arbor, MI, USA; Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, USA
| | - Lauren B Gerlach
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, USA; Department of Psychiatry, University of Michigan, Ann Arbor, MI, USA
| | - Lori A Daiello
- Center for Gerontology and Healthcare Research, Brown University School of Public Health, Providence, RI, USA; Department of Health Services, Policy & Practice, Brown University School of Public Health, Providence, RI, USA
| | - Hiren Varma
- Center for Gerontology and Healthcare Research, Brown University School of Public Health, Providence, RI, USA
| | - Derrick Lo
- Center for Gerontology and Healthcare Research, Brown University School of Public Health, Providence, RI, USA
| | - Richa Joshi
- Center for Gerontology and Healthcare Research, Brown University School of Public Health, Providence, RI, USA
| | - Julie P W Bynum
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, USA; Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Theresa I Shireman
- Center for Gerontology and Healthcare Research, Brown University School of Public Health, Providence, RI, USA; Department of Health Services, Policy & Practice, Brown University School of Public Health, Providence, RI, USA
| |
Collapse
|
13
|
Phillips OW, Kunicki Z, Jones R, Belanger E, Shireman TI, Friedman JH, Kim DS, Kluger B, Akbar U. Inpatient Mortality in Parkinson's Disease. Neurohospitalist 2023; 13:144-152. [PMID: 37064936 PMCID: PMC10091425 DOI: 10.1177/19418744231153477] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/07/2023] Open
Abstract
Introduction Although a majority of the American public prefer to die at home, a large percentage of Parkinson's disease patients die in acute care hospitals. We examine trends in the clinical and demographic characteristics of Parkinson's disease patients who die in a hospital to identify populations potentially vulnerable to unwanted inpatient mortality. Methods Patients with Parkinson's disease admitted to a hospital from 2002-2016 were identified from the National Inpatient Sample (n = 710,013) along with their associated clinical and demographic characteristics. The main outcome examined was mortality during inpatient admission. From these data, logistic regression models were estimated to obtain the odds ratios of inpatient mortality among clinical and demographic attributes, and their change over time. Results Characteristics significantly associated with increased odds of inpatient mortality included increased age (OR = 1.70 for 55-65, 2.52 for 66-75, 3.99 for 76-85, 5.72 for 86+, all P < 0.001), length of stay ≤5 days (reference; 6 + days OR = 0.37, P < 0.001), white race or ethnicity (reference; Black OR = .84 P < .001, Hispanic OR = 0.91 P = 0.01), male (reference; female OR = 0.93 P < 0.001), hospitalization in Northeast (reference; Midwest OR = 0.78, South 0.84, West OR = 0.82; all P < 0.001), higher severity of illness (moderate OR = 1.50, major OR = 2.32, extreme OR = 5.57; all P < 0.001), and mortality risk (moderate OR = 2.88, major OR = 10.92, extreme OR = 52.30; all P < 0.001). Fitted probabilities overall declined over time. Conclusion Differences exist among PD patient populations regarding likelihood of in-hospital mortality that are changing with time. Insight into which PD patients are most at risk for inpatient mortality may enable clinicians to better meet end-of-life care needs.
Collapse
Affiliation(s)
- Oliver W. Phillips
- Cleveland Clinic Center for
Neurological Restoration, Cleveland, OH, USA
| | - Zachary Kunicki
- Department of Psychiatry and Human
Behavior, Brown University, Providence, RI, USA
| | - Richard Jones
- Department of Psychiatry and Human
Behavior, Brown University, Providence, RI, USA
| | - Emmanuelle Belanger
- Department of Health Services,
Policy and Practice, Center for Gerontology and Health Care Research, Brown University, Providence, RI, USA
| | - Theresa I. Shireman
- Department of Health Services,
Policy and Practice, Center for Gerontology and Health Care Research, Brown University, Providence, RI, USA
| | | | - Duk Soo Kim
- Department of Neurology, Brown University, Providence, RI, USA
| | - Benzi Kluger
- Department of Neurology, University of Rochester Medical
Center, Rochester, NY, USA
| | - Umer Akbar
- Department of Neurology, Brown University, Providence, RI, USA
| |
Collapse
|
14
|
Richter KP, Catley D, Gajewski BJ, Faseru B, Shireman TI, Zhang C, Scheuermann TS, Mussulman LM, Nazir N, Hutcheson T, Shergina E, Ellerbeck EF. The Effects of Opt-out vs Opt-in Tobacco Treatment on Engagement, Cessation, and Costs: A Randomized Clinical Trial. JAMA Intern Med 2023; 183:331-339. [PMID: 36848129 PMCID: PMC9972241 DOI: 10.1001/jamainternmed.2022.7170] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2022] [Accepted: 12/29/2022] [Indexed: 03/01/2023]
Abstract
Importance Tobacco use causes 7 million deaths per year; most national guidelines require people who use tobacco to opt in to care by affirming they are willing to quit. Use of medications and counseling is low even in advanced economy countries. Objective To evaluate the efficacy of opt-out care vs opt-in care for people who use tobacco. Design, Setting, and Participants In Changing the Default (CTD), a Bayesian adaptive population-based randomization trial, eligible patients were randomized into study groups, treated according to group assignment, and debriefed and consented for participation at 1-month follow-up. A total of 1000 adult patients were treated at a tertiary care hospital in Kansas City. Patients were randomized from September 2016 to September 2020; final follow-up was in March 2021. Interventions At bedside, counselors screened for eligibility, conducted baseline assessment, randomized patients to study group, and provided opt-out care or opt-in care. Counselors and medical staff provided opt-out patients with inpatient nicotine replacement therapy, prescriptions for postdischarge medications, a 2-week medication starter kit, treatment planning, and 4 outpatient counseling calls. Patients could opt out of any or all elements of care. Opt-in patients willing to quit were offered each element of treatment described previously. Opt-in patients who were unwilling to quit received motivational counseling. Main Outcomes and Measures The main outcomes were biochemically verified abstinence and treatment uptake at 1 month after randomization. Results Of a total of 1000 eligible adult patients who were randomized, most consented and enrolled (270 [78%] of opt-in patients; 469 [73%] of opt-out patients). Adaptive randomization assigned 345 (64%) to the opt-out group and 645 (36%) to the opt-in group. The mean (SD) age at enrollment was 51.70 (14.56) for opt-out patients and 51.21 (14.80) for opt-out patients. Of 270 opt-in patients, 123 (45.56%) were female, and of 469 opt-out patients, 226 (48.19%) were female. Verified quit rates for the opt-out group vs the opt-in group were 22% vs 16% at month 1 and 19% vs 18% at 6 months. The Bayesian posterior probability that opt-out care was better than opt-in care was 0.97 at 1 month and 0.59 at 6 months. Treatment use for the opt-out group vs the opt-in group was 60% vs 34% for postdischarge cessation medication (bayesian posterior probability of 1.0), and 89% vs 37% for completing at least 1 postdischarge counseling call (bayesian posterior probability of 1.0). The incremental cost-effectiveness ratio was $678.60, representing the cost of each additional quit in the opt-out group. Conclusions and Relevance In this randomized clinical trial, opt-out care doubled treatment engagement and increased quit attempts, while enhancing patients' sense of agency and alliance with practitioners. Stronger and longer treatment could increase cessation. Trial Registration ClinicalTrials.gov Identifier: NCT02721082.
Collapse
Affiliation(s)
- Kimber P. Richter
- Department of Population Health, University of Kansas School of Medicine, Kansas City
| | - Delwyn Catley
- Children’s Mercy Hospitals and Clinics, Center for Children’s Healthy Lifestyles & Nutrition, Kansas City, Missouri
| | - Byron J. Gajewski
- Department of Biostatistics and Data Science, University of Kansas School of Medicine, Kansas City
| | - Babalola Faseru
- Department of Population Health, University of Kansas School of Medicine, Kansas City
| | - Theresa I. Shireman
- Department of Health Services, Policy, and Practice, Brown University, Providence, Rhode Island
| | | | | | - Laura M. Mussulman
- Department of Population Health, University of Kansas School of Medicine, Kansas City
| | - Niaman Nazir
- Department of Population Health, University of Kansas School of Medicine, Kansas City
| | - Tresza Hutcheson
- Department of Population Health, University of Kansas School of Medicine, Kansas City
| | - Elena Shergina
- Department of Biostatistics and Data Science, University of Kansas School of Medicine, Kansas City
| | - Edward F. Ellerbeck
- Department of Population Health, University of Kansas School of Medicine, Kansas City
| |
Collapse
|
15
|
Schmidt C, Borgia M, Zhang T, Gochyyev P, Shireman TI, Resnik L. Initial treatment approaches and healthcare utilization among veterans with low back pain: a propensity score analysis. BMC Health Serv Res 2023; 23:275. [PMID: 36944926 PMCID: PMC10029316 DOI: 10.1186/s12913-023-09207-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2022] [Accepted: 02/21/2023] [Indexed: 03/23/2023] Open
Abstract
BACKGROUND Opioid prescriptions for Veterans with low back pain (LBP) persist despite the availability of PT, a lower medical risk treatment option. Patterns of treatment and subsequent healthcare utilization for Veterans with LBP are unknown. The purpose of this study was to evaluate the association of physical therapy (PT) and opioids and outcomes of spinal surgery and chronic opioid use for Veterans with incident LBP. METHODS We conducted a retrospective cohort study identifying Veterans with a new diagnosis of LBP using ICD codes from the Veterans Administration national database from 2012 to 2017. Veterans were classified into three treatment groups based on the first treatment received within 30 days of incident LBP: receipt of PT, opioids, or neither PT nor opioids. Outcomes, events of spinal surgery and chronic opioid use, were identified beginning on day 31 up to one year following initial treatment. We used propensity score matching to account for the potential selection bias in evaluating the associations between initial treatment and outcomes. RESULTS There were 373,717 incident cases of LBP between 2012 and 2017. Of those 28,850 (7.7%) received PT, 48,978 (13.1%) received opioids, and 295,889 (79.2%) received neither PT or opioids. Pain, marital status and the presence of cardiovascular, pulmonary, or metabolic chronic conditions had the strongest statistically significant differences between treatment groups. Veterans receiving opioids compared to no treatment had higher odds of having a spinal surgery (2.04, 99% CI: 1.67, 2.49) and progressing to chronic opioid use (11.8, 99% CI: 11.3, 12.3). Compared to Veterans receiving PT those receiving opioids had higher odds (1.69, 99% CI: 1.21, 2.37) of having spinal surgery and progressing to chronic opioid use (17.8, 99% CI: 16.0, 19.9). CONCLUSION Initiating treatment with opioids compared to PT was associated with higher odds of spinal surgery and chronic opioid use for Veterans with incident LBP. More Veterans received opioids compared to PT as an initial treatment for incident LBP. Our findings can inform rehabilitation care practices for Veterans with incident LBP.
Collapse
Affiliation(s)
- Catherine Schmidt
- Department of Physical Therapy, MGH Institute of Health Professions, 36 1st Avenue, Boston, MA, 02129-4557, USA.
- Providence VA Medical Center, 830 Chalkstone Avenue, Providence, RI, 02912, USA.
- Department of Health Services, Policy and Practice: Center for Gerontology and Health Care Research, Brown University, Providence, RI, 02912, USA.
| | - Matthew Borgia
- Providence VA Medical Center, 830 Chalkstone Avenue, Providence, RI, 02912, USA
| | - Tingting Zhang
- Department of Health Services, Policy and Practice: Center for Gerontology and Health Care Research, Brown University, Providence, RI, 02912, USA
| | - Perman Gochyyev
- Department of Physical Therapy, MGH Institute of Health Professions, 36 1st Avenue, Boston, MA, 02129-4557, USA
| | - Theresa I Shireman
- Department of Health Services, Policy and Practice: Center for Gerontology and Health Care Research, Brown University, Providence, RI, 02912, USA
| | - Linda Resnik
- Providence VA Medical Center, 830 Chalkstone Avenue, Providence, RI, 02912, USA
- Department of Health Services, Policy and Practice: Center for Gerontology and Health Care Research, Brown University, Providence, RI, 02912, USA
| |
Collapse
|
16
|
Coe AB, Montoya A, Chang CH, Park PS, Bynum JP, Shireman TI, Zhang T, McCreedy EM, Gerlach LB. Behavioral symptoms, depression symptoms, and medication use in Michigan nursing home residents with dementia during COVID-19. J Am Geriatr Soc 2023; 71:414-422. [PMID: 36349415 PMCID: PMC9877723 DOI: 10.1111/jgs.18116] [Citation(s) in RCA: 12] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2022] [Revised: 09/21/2022] [Accepted: 10/09/2022] [Indexed: 11/11/2022]
Abstract
BACKGROUND The COVID-19 pandemic significantly disrupted nursing home (NH) care, including visitation restrictions, reduced staffing levels, and changes in routine care. These challenges may have led to increased behavioral symptoms, depression symptoms, and central nervous system (CNS)-active medication use among long-stay NH residents with dementia. METHODS We conducted a retrospective, cross-sectional study including Michigan long-stay (≥100 days) NH residents aged ≥65 with dementia based on Minimum Data Set (MDS) assessments from January 1, 2018 to June 30, 2021. Residents with schizophrenia, Tourette syndrome, or Huntington's disease were excluded. Outcomes were the monthly prevalence of behavioral symptoms (i.e., Agitated Reactive Behavior Scale ≥ 1), depression symptoms (i.e., Patient Health Questionnaire [PHQ]-9 ≥ 10, reflecting at least moderate depression), and CNS-active medication use (e.g., antipsychotics). Demographic, clinical, and facility characteristics were included. Using an interrupted time series design, we compared outcomes over two periods: Period 1: January 1, 2018-February 28, 2020 (pre-COVID-19) and Period 2: March 1, 2020-June 30, 2021 (during COVID-19). RESULTS We included 37,427 Michigan long-stay NH residents with dementia. The majority were female, 80 years or older, White, and resided in a for-profit NH facility. The percent of NH residents with moderate depression symptoms increased during COVID-19 compared to pre-COVID-19 (4.0% vs 2.9%, slope change [SC] = 0.03, p < 0.05). Antidepressant, antianxiety, antipsychotic and opioid use increased during COVID-19 compared to pre-COVID-19 (SC = 0.41, p < 0.001, SC = 0.17, p < 0.001, SC = 0.07, p < 0.05, and SC = 0.24, p < 0.001, respectively). No significant changes in hypnotic use or behavioral symptoms were observed. CONCLUSIONS Michigan long-stay NH residents with dementia had a higher prevalence of depression symptoms and CNS active-medication use during the COVID-19 pandemic than before. During periods of increased isolation, facility-level policies to regularly assess depression symptoms and appropriate CNS-active medication use are warranted.
Collapse
Affiliation(s)
- Antoinette B. Coe
- Department of Clinical Pharmacy, University of Michigan College of Pharmacy, Ann Arbor, Michigan, Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, Michigan
| | - Ana Montoya
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, Michigan, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan
| | - Chiang-Hua Chang
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, Michigan
| | - Pil S. Park
- Institute of Gerontology, University of Michigan, Ann Arbor, Michigan
| | - Julie P.W. Bynum
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, Michigan, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, Institute of Gerontology, University of Michigan, Ann Arbor, Michigan
| | - Theresa I. Shireman
- Center for Gerontology and Health Care Research, Brown University School of Public Health, Providence, Rhode Island, Department of Health Services, Policy and Practice, Brown University School of Public Health, Providence Rhode Island
| | - Tingting Zhang
- Center for Gerontology and Health Care Research, Brown University School of Public Health, Providence, Rhode Island, Department of Health Services, Policy and Practice, Brown University School of Public Health, Providence Rhode Island
| | - Ellen M. McCreedy
- Center for Gerontology and Health Care Research, Brown University School of Public Health, Providence, Rhode Island, Department of Health Services, Policy and Practice, Brown University School of Public Health, Providence Rhode Island
| | - Lauren B. Gerlach
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, Michigan, Department of Psychiatry, University of Michigan, Ann Arbor, Michigan
| |
Collapse
|
17
|
Hughto JMW, Varma H, Babbs G, Yee K, Alpert A, Hughes L, Ellison J, Downing J, Shireman TI. Disparities in health condition diagnoses among aging transgender and cisgender medicare beneficiaries, 2008-2017. Front Endocrinol (Lausanne) 2023; 14:1102348. [PMID: 36992801 PMCID: PMC10040837 DOI: 10.3389/fendo.2023.1102348] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [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: 11/18/2022] [Accepted: 02/21/2023] [Indexed: 03/14/2023] Open
Abstract
INTRODUCTION The objective of this research is to provide national estimates of the prevalence of health condition diagnoses among age-entitled transgender and cisgender Medicare beneficiaries. Quantification of the health burden across sex assigned at birth and gender can inform prevention, research, and allocation of funding for modifiable risk factors. METHODS Using 2009-2017 Medicare fee-for-service data, we implemented an algorithm that leverages diagnosis, procedure, and pharmacy claims to identify age-entitled transgender Medicare beneficiaries and stratify the sample by inferred gender: trans feminine and nonbinary (TFN), trans masculine and nonbinary (TMN), and unclassified. We selected a 5% random sample of cisgender individuals for comparison. We descriptively analyzed (means and frequencies) demographic characteristics (age, race/ethnicity, US census region, months of enrollment) and used chi-square and t-tests to determine between- (transgender vs. cisgender) and within-group gender differences (e.g., TMN, TFN, unclassified) difference in demographics (p<0.05). We then used logistic regression to estimate and examine within- and between-group gender differences in the predicted probability of 25 health conditions, controlling for age, race/ethnicity, enrollment length, and census region. RESULTS The analytic sample included 9,975 transgender (TFN n=4,198; TMN n=2,762; unclassified n=3,015) and 2,961,636 cisgender (male n=1,294,690, female n=1,666,946) beneficiaries. The majority of the transgender and cisgender samples were between the ages of 65 and 69 and White, non-Hispanic. The largest proportion of transgender and cisgender beneficiaries were from the South. On average, transgender individuals had more months of enrollment than cisgender individuals. In adjusted models, aging TFN or TMN Medicare beneficiaries had the highest probability of each of the 25 health diagnoses studied relative to cisgender males or females. TFN beneficiaries had the highest burden of health diagnoses relative to all other groups. DISCUSSION These findings document disparities in key health condition diagnoses among transgender Medicare beneficiaries relative to cisgender individuals. Future application of these methods will enable the study of rare and anatomy-specific conditions among hard-to-reach aging transgender populations and inform interventions and policies to address documented disparities.
Collapse
Affiliation(s)
- Jaclyn M. W. Hughto
- Center for Health Promotion and Health Equity, Brown University School of Public Health, Providence, RI, United States
- Departments of Behavioral and Social Sciences and Epidemiology, Brown University School of Public Health, Providence, RI, United States
- The Fenway Institute, Fenway Health, Boston, MA, United States
- *Correspondence: Jaclyn M. W. Hughto,
| | - Hiren Varma
- Center for Gerontology & Healthcare Research, Brown University School of Public Health, Providence, RI, United States
- Department of Health Services Policy & Practice, Brown University School of Public Health, Providence, RI, United States
| | - Gray Babbs
- Center for Gerontology & Healthcare Research, Brown University School of Public Health, Providence, RI, United States
- Department of Health Services Policy & Practice, Brown University School of Public Health, Providence, RI, United States
| | - Kim Yee
- Oregon Health & Science University - Portland State University School of Public Health, Portland, OR, United States
| | - Ash Alpert
- Center for Gerontology & Healthcare Research, Brown University School of Public Health, Providence, RI, United States
- Department of Health Services Policy & Practice, Brown University School of Public Health, Providence, RI, United States
- Department of Public Health Sciences, University of Rochester Medical Center, Rochester, NY, United States
| | - Landon Hughes
- Department of Health Behavior and Health Education, University of Michigan School of Public Health, Ann Arbor, MI, United States
- Institute for Social Research, University of Michigan, Ann Arbor, MI, United States
| | - Jacqueline Ellison
- Department of Health Policy and Management, University of Pittsburgh School of Public Health, Pittsburgh, PA, United States
- Center for Innovative Research on Gender Health Equity (CONVERGE), University of Pittsburgh Department of Medicine, Pittsburgh, PA, United States
| | - Jae Downing
- Oregon Health & Science University - Portland State University School of Public Health, Portland, OR, United States
| | - Theresa I. Shireman
- Center for Gerontology & Healthcare Research, Brown University School of Public Health, Providence, RI, United States
- Department of Health Services Policy & Practice, Brown University School of Public Health, Providence, RI, United States
| |
Collapse
|
18
|
Coe AB, Zhang T, Zullo AR, Gerlach LB, Thomas KS, Daiello LA, Varma H, Lo D, Joshi R, Shireman TI, Bynum JP. Psychotropic medication prescribing in assisted living and nursing home residents with dementia after the National Partnership. J Am Geriatr Soc 2022; 70:3513-3525. [PMID: 35984088 PMCID: PMC9771901 DOI: 10.1111/jgs.18004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2022] [Revised: 06/30/2022] [Accepted: 07/27/2022] [Indexed: 12/24/2022]
Abstract
BACKGROUND The Centers for Medicare & Medicaid Services implemented the National Partnership to Improve Dementia Care in Nursing Homes (the Partnership) to decrease antipsychotic use and improve care for nursing home (NH) residents with dementia. We determined whether the extent of antipsychotic and other psychotropic medication prescribing in AL residents with dementia mirrored that of long-stay NH (LSNH) residents after the Partnership. METHODS Using a 20% sample of fee-for-service Medicare beneficiaries with Part D, we conducted a retrospective cohort study including AL and LSNH residents with dementia. The monthly prevalence of psychotropic medication prescribing (antipsychotics, antidepressants, anxiolytics/sedative-hypnotics, anticonvulsants/mood stabilizers, benzodiazepines, and antidementia medications) was examined. We used an interrupted time-series analysis to compare medication prescribing before (July 1, 2010-March 31, 2012) and after (April 1, 2012-December 31, 2017) the Partnership in both settings. RESULTS We identified 107,931 beneficiaries with ≥1 month as an AL resident and 323,766 beneficiaries with ≥1 month as a LSNH resident with dementia, including 1,923,867 person-months and 4,984,405 person-months, respectively. Antipsychotic prescribing declined over the study period in both settings. After the launch of the Partnership, the rate of decline in antipsychotic prescribing slowed in AL residents with dementia (slope change = 0.03 [95% CLs: 0.02, 0.04]) while the rate of decline in antipsychotic prescribing increased in LSNH residents with dementia (slope change = -0.12 [95% CLs: -0.16, -0.08]). Antidepressants were the most prevalent medication prescribed, anticonvulsant/mood stabilizer prescribing increased, and anxiolytic/sedative-hypnotic and antidementia medication prescribing declined. CONCLUSIONS The federal Partnership to reduce antipsychotic prescribing in NH residents did not appear to affect antipsychotic prescribing in AL residents with dementia. Given the increase in the prescribing of mood stabilizers/anticonvulsants that occurred after the launch of the Partnership, monitoring may be warranted for all psychotropic medications in AL and NH settings.
Collapse
Affiliation(s)
- Antoinette B. Coe
- Department of Clinical Pharmacy, College of Pharmacy, University of Michigan, Ann Arbor, Michigan, USA., Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, Michigan, USA
| | - Tingting Zhang
- Center for Gerontology and Healthcare Research, Brown University School of Public Health, Providence, Rhode Island, USA
| | - Andrew R. Zullo
- Center for Gerontology and Healthcare Research, Brown University School of Public Health, Providence, Rhode Island, USA., Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, Rhode Island, USA., Department of Epidemiology, Brown University School of Public Health, Providence, Rhode Island, USA., Center of Innovation in Long-Term Services and Supports, Providence Veterans Affairs Medical Center, Providence, Rhode Island, USA
| | - Lauren B. Gerlach
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, Michigan, USA., Department of Psychiatry, University of Michigan, Ann Arbor, Michigan, USA
| | - Kali S. Thomas
- Center for Gerontology and Healthcare Research, Brown University School of Public Health, Providence, Rhode Island, USA., Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, Rhode Island, USA., Center of Innovation in Long-Term Services and Supports, Providence Veterans Affairs Medical Center, Providence, Rhode Island, USA
| | - Lori A. Daiello
- Center for Gerontology and Healthcare Research, Brown University School of Public Health, Providence, Rhode Island, USA., Department of Neurology, The Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
| | - Hiren Varma
- Center for Gerontology and Healthcare Research, Brown University School of Public Health, Providence, Rhode Island, USA
| | - Derrick Lo
- Center for Gerontology and Healthcare Research, Brown University School of Public Health, Providence, Rhode Island, USA
| | - Richa Joshi
- Center for Gerontology and Healthcare Research, Brown University School of Public Health, Providence, Rhode Island, USA
| | - Theresa I. Shireman
- Center for Gerontology and Healthcare Research, Brown University School of Public Health, Providence, Rhode Island, USA
| | - Julie P.W. Bynum
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, Michigan, USA., Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
| |
Collapse
|
19
|
Haji M, Lopes VV, Ge A, Halladay C, Soares C, Shah NR, Longenecker CT, Lally M, Bloomfield GS, Shireman TI, Ross D, Sullivan JL, Rudolph JL, Wu WC, Erqou S. Two decade trends in cardiovascular disease outcomes and cardiovascular risk factors among US veterans living with HIV. Int J Cardiol Cardiovasc Risk Prev 2022; 15:200151. [PMID: 36573195 PMCID: PMC9789359 DOI: 10.1016/j.ijcrp.2022.200151] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/16/2022] [Revised: 08/29/2022] [Accepted: 09/19/2022] [Indexed: 12/30/2022]
Abstract
Coomprhensive data on temporal trends in cardiovascular disease (CVD) risk factors and outcomes in people living with HIV are limited. Using retrospective data on 50,284 US Veterans living with HIV (VLWH) who received care in the VA from 2001 to 2019, we calculated the prevalence and incidence estimates of CVD risk factors and outcomes, as well as the average annual percent changes (AAPC) in the estimates. The mean age of the Veterans increased from 47.8 (9.1) years to 58.0 (12.4) years during the study period. The population remained predominantly (>95%) male and majority Black (∼50%). The prevalence of the CVD outcomes increased progressively over the study period: coronary artery disease (3.9%-18.7%), peripheral artery disease (2.3%, 10.3%), ischemic cerebrovascular disease (1.1%-9.9%), and heart failure (2.4%-10.5%). There was a progressive increase in risk factor burden, except for smoking which declined after 2015. The AAPC in prevalence was statistically significant for the CVD outcomes and risk factors. When adjusted for age, the predicted prevalence of CVD risk factors and outcomes showed comparable (but attenuated) trends. There was generally a comparable (but attenuated) trend in incidence of CVD outcomes, procedures, and risk factors over the study period. The use of statins increased from 10.6% (2001) to 40.8% (2019). Antiretroviral therapy usage increased from 77.7% (2001) to 85.0% (2019). In conclusion, in a retrospective analysis of large-scale VA data we found the burden and incidence of several CVD risk factors and outcomes have increased among VLWH over the past 20 years.
Collapse
Affiliation(s)
- Mohammed Haji
- Department of Medicine, Brown University, Providence, RI, USA
| | - Vrishali V. Lopes
- Center of Innovation in Long Term Services & Supports, Providence VA Medical Center, Providence, RI, USA
| | - Augustus Ge
- Center of Innovation in Long Term Services & Supports, Providence VA Medical Center, Providence, RI, USA
| | - Christopher Halladay
- Center of Innovation in Long Term Services & Supports, Providence VA Medical Center, Providence, RI, USA
| | - Cullen Soares
- Department of Medicine, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Nishant R. Shah
- Department of Medicine, Brown University, Providence, RI, USA
- Department of Medicine, Providence VA Medical Center, Providence, RI, USA
- Brown University School of Public Health, Brown University, Providence, RI, USA
| | | | - Michelle Lally
- Department of Medicine, Brown University, Providence, RI, USA
- Department of Medicine, Providence VA Medical Center, Providence, RI, USA
| | - Gerald S. Bloomfield
- Duke Clinical Research Institute, Duke Global Health Institute and Department of Medicine, Duke University, Durham, NC, USA
| | - Theresa I. Shireman
- Brown University School of Public Health, Brown University, Providence, RI, USA
| | - David Ross
- Office of Specialty Care Service, US Department of Veterans Affairs, USA
- Infectious Disease Section, Washington, DC Department of Veterans Affairs Medical Center, USA
| | - Jennifer L. Sullivan
- Center of Innovation in Long Term Services & Supports, Providence VA Medical Center, Providence, RI, USA
- Department of Medicine, Providence VA Medical Center, Providence, RI, USA
- Brown University School of Public Health, Brown University, Providence, RI, USA
| | - James L. Rudolph
- Department of Medicine, Brown University, Providence, RI, USA
- Center of Innovation in Long Term Services & Supports, Providence VA Medical Center, Providence, RI, USA
- Department of Medicine, Providence VA Medical Center, Providence, RI, USA
- Brown University School of Public Health, Brown University, Providence, RI, USA
| | - Wen-Chih Wu
- Department of Medicine, Brown University, Providence, RI, USA
- Center of Innovation in Long Term Services & Supports, Providence VA Medical Center, Providence, RI, USA
- Department of Medicine, Providence VA Medical Center, Providence, RI, USA
- Brown University School of Public Health, Brown University, Providence, RI, USA
| | - Sebhat Erqou
- Department of Medicine, Brown University, Providence, RI, USA
- Center of Innovation in Long Term Services & Supports, Providence VA Medical Center, Providence, RI, USA
- Department of Medicine, Providence VA Medical Center, Providence, RI, USA
- Corresponding author. Division of Cardiology, Providence VA Medical Center, Providence, RI, USA.
| |
Collapse
|
20
|
Lipori JP, Tu E, Shireman TI, Gerlach L, Coe AB, Ryskina KL. Factors Associated with Potentially Harmful Medication Prescribing in Nursing Homes: A Scoping Review. J Am Med Dir Assoc 2022; 23:1589.e1-1589.e10. [PMID: 35868350 PMCID: PMC10101239 DOI: 10.1016/j.jamda.2022.06.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2022] [Revised: 06/07/2022] [Accepted: 06/12/2022] [Indexed: 11/18/2022]
Abstract
OBJECTIVES To summarize current evidence regarding facility and prescriber characteristics associated with potentially harmful medication (PHM) use by residents in nursing homes (NHs), which could inform the development of interventions to reduce this potentially harmful practice. DESIGN Scoping review. SETTING AND PARTICIPANTS Studies conducted in the United States that described facility and prescriber factors associated with PHM use in NHs. METHODS Electronic searches of PubMed/MEDLINE were conducted for articles published in English between April 2011 and November 2021. PHMs were defined based on the Beers List criteria. Studies testing focused interventions targeting PHM prescribing or deprescribing were excluded. Studies were characterized by the strengths and weaknesses of the analytic approach and generalizability. RESULTS Systematic search yielded 1253 articles. Of these, 29 were assessed in full text and 20 met inclusion criteria. Sixteen examined antipsychotic medication (APM) use, 2 anticholinergic medications, 1 sedative-hypnotics, and 2 overall PHM use. APM use was most commonly associated with facilities with a higher proportion of male patients, younger patients, and patients with severe cognitive impairment, anxiety, depression, and aggressive behavior. The use of APM and anticholinergic medications was associated with low registered nurse staffing ratios and for-profit facility status. No studies evaluated prescriber characteristics. CONCLUSIONS AND IMPLICATIONS Included studies primarily examined APM use. The most commonly reported facility characteristics were consistent with previously reported indicators of poor NH quality and NHs with patient case mix more likely to use PHMs.
Collapse
Affiliation(s)
- Jessica P Lipori
- Division of General Internal Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Emily Tu
- Division of General Internal Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Theresa I Shireman
- Center for Gerontology and Healthcare Research, Brown University School of Public Health, Providence, RI, USA
| | - Lauren Gerlach
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, USA
| | - Antoinette B Coe
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, USA; Department of Clinical Pharmacy, College of Pharmacy, University of Michigan, Ann Arbor, MI, USA
| | - Kira L Ryskina
- Division of General Internal Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA; Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA.
| |
Collapse
|
21
|
Rofé KL, Marshall BD, Merlin JS, Trivedi AN, Shireman TI, Schmidt C, Moyo P. Nonpharmacologic management of chronic pain in the United States’ Medicare population: a scoping review protocol. JBI Evid Synth 2022; 20:2361-2369. [PMID: 35976050 PMCID: PMC9594142 DOI: 10.11124/jbies-21-00467] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
Abstract
Objective: Introduction: Inclusion criteria: Methods: Scoping review registration:
Collapse
Affiliation(s)
- Kara L. Rofé
- School of Public Health, Brown University, Providence, RI, USA
| | - Brandon D.L. Marshall
- School of Public Health, Brown University, Providence, RI, USA
- Department of Epidemiology, School of Public Health, Brown University, Providence, RI, USA
| | - Jessica S. Merlin
- Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
- Division of Infectious Diseases, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Amal N. Trivedi
- School of Public Health, Brown University, Providence, RI, USA
- Department of Medicine, Brown University, Providence, RI, USA
- Center for Gerontology and Healthcare Research, Department of Health Services, Policy and Practice, School of Public Health, Brown University, Providence, RI, USA
| | - Theresa I. Shireman
- School of Public Health, Brown University, Providence, RI, USA
- Center for Gerontology and Healthcare Research, Department of Health Services, Policy and Practice, School of Public Health, Brown University, Providence, RI, USA
| | - Catherine Schmidt
- Department of Physical Therapy, Massachusetts General Hospital Institute of Health Professions School of Health and Rehabilitation Sciences, Boston, MA, USA
| | - Patience Moyo
- School of Public Health, Brown University, Providence, RI, USA
- Center for Gerontology and Healthcare Research, Department of Health Services, Policy and Practice, School of Public Health, Brown University, Providence, RI, USA
| |
Collapse
|
22
|
Zhang T, Shireman TI, Meyers DJ, Zullo A, Lee Y, Wilson IB. Use of antiretroviral therapy in nursing home residents with HIV. J Am Geriatr Soc 2022; 70:1800-1806. [PMID: 35332518 PMCID: PMC10103632 DOI: 10.1111/jgs.17763] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2021] [Revised: 02/28/2022] [Accepted: 03/09/2022] [Indexed: 11/30/2022]
Abstract
BACKGROUND Antiretroviral therapies (ARTs) are essential HIV care. As people living with HIV age and their presence in nursing homes (NHs) increases, it is critical to evaluate the quality of HIV care. We determine the rate of ART use and examine individual- and facility-level characteristics associated with no ART use in a nationally representative long-stay NH residents with HIV. METHODS This retrospective cohort study included all long-stay Medicare fee-for-service NH residents (2013-2016) with HIV who had a valid Minimum Data Set assessment. Residents were followed from long-stay qualification until death, Part D disenrollment, transfer from long-term care to another healthcare setting, or December 31, 2016. We identified individual and facility characteristics that were associated with non-use of ART using generalized estimating equation logistic regression. RESULTS Exactly 4171 eligible HIV+ residents from 2459 NHs were included in our study. Only 36% (1507 of 4171) received any ART regimen during an average of 11.6 months of observation. Older age, females, white race, receipt of Medicare skilled nursing benefits, and some major cardiometabolic comorbidities and mental health conditions were associated with non-ART use. Rates of non-ART use did not vary significantly by residents' end-of-life status (p = 0.21). Residents in facilities with a higher HIV concentration [adjusted odds ratio (adjOR) 3.42; 95% confidence interval (CI) 2.13-5.48] and an AIDS unit (adjOR 2.51; 95% CI 1.92-3.30) had higher odds of using an ART. CONCLUSIONS AND IMPLICATIONS The rate of ART use by HIV+ long-stay NH residents was low. Facilities' experience with HIV played an important role in ART receipt. Interventions to improve rates of ART use in NHs are urgently needed to ensure optimal health outcomes.
Collapse
Affiliation(s)
- Tingting Zhang
- Department of Health Services, Policy & Practice, Brown University School of Public Health, Providence, Rhode Island, USA
| | - Theresa I Shireman
- Department of Health Services, Policy & Practice, Brown University School of Public Health, Providence, Rhode Island, USA
| | - David J Meyers
- Department of Health Services, Policy & Practice, Brown University School of Public Health, Providence, Rhode Island, USA
| | - Andrew Zullo
- Department of Health Services, Policy & Practice, Brown University School of Public Health, Providence, Rhode Island, USA
| | - Yoojin Lee
- Department of Health Services, Policy & Practice, Brown University School of Public Health, Providence, Rhode Island, USA
| | - Ira B Wilson
- Department of Health Services, Policy & Practice, Brown University School of Public Health, Providence, Rhode Island, USA
| |
Collapse
|
23
|
Jain N, Martin BC, Dai J, Phadnis MA, Al-Hindi L, Shireman TI, Hedayati SS, Rasu RS, Mehta JL. Age Modifies Intracranial and Gastrointestinal Bleeding Risk from P2Y 12 Inhibitors in Patients Receiving Dialysis. Kidney360 2022; 3:1374-1383. [PMID: 36176642 PMCID: PMC9416835 DOI: 10.34067/kid.0002442022] [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] [Received: 04/01/2022] [Accepted: 05/16/2022] [Indexed: 01/11/2023]
Abstract
Background Individuals aged ≥75 years are the fastest-growing population starting dialysis for end-stage kidney disease (ESKD) due to living longer with coronary artery disease. ESKD alone can increase bleeding risk, but P2Y12 inhibitor (P2Y12-I) antiplatelet medications prescribed for cardiovascular treatment can exacerbate this risk in patients with ESKD. The age-specific rates of bleeding complications in dialysis patients with ESKD on P2Y12-I remain unclear, as does how age modifies the bleeding risk from P2Y12-I use in these patients. Methods In a retrospective cohort study, we collected data on 40,972 patients receiving maintenance hemo- or peritoneal dialysis who were newly prescribed P2Y12-I therapy between 2011 and 2015 from the USRDS registry. We analyzed the effect of age on the time to first bleed and the interactions between age and P2Y12-I type on modifying the effects of a bleed. Results Twenty percent of the cohort were aged ≥75 years. There were 3096 (8%) gastrointestinal (GI) and 1298 (3%) intracranial (IC) bleeding events during a median follow-up of 1 year. Annual incidence rates for IC bleeds were 2% in those aged <55 years and 3% in those aged ≥75 years. Rates for GI bleeds were 4% in those aged <55 years and 9% in those aged ≥75 years. On clopidogrel, prasugrel, and ticagrelor, for every decade increase in age of the cohort members, the risk of IC bleed increased by 9%, 55%, and 59%, and the risk of GI bleed increased by 21%, 28%, and 39%, respectively. At age ≥75 years, prasugrel was associated with a greater risk of IC bleed than clopidogrel. At age ≥60 years, ticagrelor was associated with a greater risk of GI bleed than clopidogrel. Conclusions More potent P2Y12-Is (prasugrel and ticagrelor) were associated with a disproportionately higher risk of IC bleed with increasing age compared with that of clopidogrel-prasugrel was much worse than clopidogrel at age ≥75 years. All three drugs were associated with only modest increase in the risk of GI bleed with every decade increase in age-ticagrelor was much worse than clopidogrel at ≥60 years of age. These results highlight the need for head-to-head clinical trials for the use of P2Y12-Is in patients with ESKD to determine age cutoffs where the risk of bleeding outweighs the benefits of thrombosis prevention.
Collapse
Affiliation(s)
- Nishank Jain
- Department of Medicine, University of Arkansas for Medical Sciences, Little Rock, Arkansas,Medicine Service, Central Arkansas Veterans Affairs Medical Center, Little Rock, Arkansas
| | - Bradley C. Martin
- Division of Pharmaceutical Evaluation and Policy, University of Arkansas for Medical Sciences, Little Rock, Arkansas
| | - Junqiang Dai
- Department of Biostatistics and Data Science, University of Kansas School of Medicine, Kansas City, Kansas
| | - Milind A. Phadnis
- Department of Biostatistics and Data Science, University of Kansas School of Medicine, Kansas City, Kansas
| | - Layth Al-Hindi
- Department of Medicine, University of Arkansas for Medical Sciences, Little Rock, Arkansas
| | - Theresa I. Shireman
- Department of Health Services, Policy and Practice, Brown University, Providence, Rhode Island
| | - S. Susan Hedayati
- Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Rafia S. Rasu
- Department of Pharmacotherapy, University of North Texas Health Sciences, Fort Worth, Texas
| | - Jawahar L. Mehta
- Department of Medicine, University of Arkansas for Medical Sciences, Little Rock, Arkansas,Medicine Service, Central Arkansas Veterans Affairs Medical Center, Little Rock, Arkansas
| |
Collapse
|
24
|
Moyo P, Schmidt C, Lee Y, Joshi R, Mukhdomi T, Trivedi A, Shireman TI. Receipt of Physical Therapy and Chiropractic Care by Adults Diagnosed with Chronic Pain: Analysis of the 2016-2018 Rhode Island All Payer Claims Database. R I Med J (2013) 2022; 105:51-56. [PMID: 35476739 PMCID: PMC9186019] [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] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
OBJECTIVE To examine trends and factors associated with physical therapy (PT) and chiropractic care use among Rhode Islanders with private or publicly-funded health insurance who were diagnosed with chronic pain from 2016-2018. METHODS We measured monthly PT and chiropractic care use from the RI All Payer Claims Database, and conducted logistic regression to identify factors associated with utilization. RESULTS There were 284,942 unique adults with chronic pain representing over one-quarter of insured persons in the state. Chiropractic care use remained unchanged but was more prevalent (7.2%) than PT whose use increased minimally from 4.0% (2016) to 4.5% (2018). Traditional Medicare or Medicaid enrollment was associated with lower odds of receiving PT and chiropractic care than in private plans. CONCLUSIONS PT and chiropractic care use varied across payers; however, there were little to no changes in their use over time despite clinical guidelines that encourage non-pharmacologic options to manage chronic pain.
Collapse
Affiliation(s)
- Patience Moyo
- Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, RI
| | - Catherine Schmidt
- Department of Physical Therapy, Massachusetts General Hospital Institute of Health Professions School of Health and Rehabilitation Sciences, Boston, MA
| | - Yoojin Lee
- Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, RI
| | - Richa Joshi
- Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, RI
| | - Taif Mukhdomi
- Department of Anesthesiology, Rhode Island Hospital, Warren Alpert Medical School of Brown University, Providence, RI
| | - Amal Trivedi
- Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, RI
| | - Theresa I Shireman
- Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, RI
| |
Collapse
|
25
|
Hughto JM, Hughes L, Yee K, Downing J, Ellison J, Alpert A, Jasuja G, Shireman TI. Improving Data-Driven Methods to Identify and Categorize Transgender Individuals by Gender in Insurance Claims Data. LGBT Health 2022; 9:254-263. [PMID: 35290746 PMCID: PMC9150133 DOI: 10.1089/lgbt.2021.0433] [Citation(s) in RCA: 2] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Purpose: Prior algorithms enabled the identification and gender categorization of transgender people in insurance claims databases in which sex and gender are not simultaneously captured. However, these methods have been unable to categorize the gender of a large proportion of their samples. We improve upon these methods to identify the gender of a larger proportion of transgender people in insurance claims data. Methods: Using 2001-2019 Optum's Clinformatics® Data Mart insurance claims data, we adapted prior algorithms by combining diagnosis, procedure, and pharmacy claims to (1) identify a transgender sample; and (2) stratify the sample by gender category (trans feminine and nonbinary [TFN], trans masculine and nonbinary [TMN], unclassified). We used logistic regression to estimate the burden of 13 chronic health conditions, controlling for gender category, age, race/ethnicity, enrollment length, and census region. Results: We identified 38,598 unique transgender people, comprising 50% [n = 19,252] TMN, 26% (n = 10,040) TFN, and 24% (n = 9306) unclassified individuals. In adjusted models, relative to TMN people, TFN people had significantly higher odds of most chronic health conditions, including HIV, atherosclerotic cardiovascular disorder, myocardial infarction, alcohol use disorder, and drug use disorder. Notably, TMN individuals had significantly higher odds of post-traumatic stress disorder and depression than TFN individuals. Conclusion: By combining complex administrative claims-based algorithms, we identified the largest U.S.-based sample of transgender individuals and inferred the gender of >75% of the sample. Adjusted models extend prior research documenting key health disparities by gender category. These methods may enable researchers to explore rare and sex-specific conditions in hard-to-reach transgender populations.
Collapse
Affiliation(s)
- Jaclyn M.W. Hughto
- Center for Health Promotion and Health Equity, Brown University School of Public Health, Providence, Rhode Island, USA
- Department of Behavioral and Social Sciences, Brown University School of Public Health, Providence, Rhode Island, USA
- Department of Epidemiology, Brown University School of Public Health, Providence, Rhode Island, USA
- The Fenway Institute, Fenway Health, Boston, Massachusetts, USA
| | - Landon Hughes
- Department of Health Behavior and Health Education, University of Michigan School of Public Health, Ann Arbor, Michigan, USA
- Population Studies Center, Institute for Social Research, University of Michigan, Ann Arbor, Michigan, USA
| | - Kim Yee
- Health Policy and Management, Oregon Health and Science University-Portland State University School of Public Health, Portland, Oregon, USA
| | - Jae Downing
- Health Policy and Management, Oregon Health and Science University-Portland State University School of Public Health, Portland, Oregon, USA
| | - Jacqueline Ellison
- Department of Health Services Policy and Practice, Brown University School of Public Health, Providence, Rhode Island, USA
- Center for Gerontology and Healthcare Research, Brown University School of Public Health, Providence, Rhode Island, USA
| | - Ash Alpert
- Department of Health Services Policy and Practice, Brown University School of Public Health, Providence, Rhode Island, USA
- Center for Gerontology and Healthcare Research, Brown University School of Public Health, Providence, Rhode Island, USA
| | - Guneet Jasuja
- Center for Healthcare Organization and Implementation Research, VA Bedford Healthcare System, Bedford, Massachusetts, USA
- Section of General Internal Medicine, Boston University School of Medicine, Boston, Massachusetts, USA
| | - Theresa I. Shireman
- Department of Health Services Policy and Practice, Brown University School of Public Health, Providence, Rhode Island, USA
- Center for Gerontology and Healthcare Research, Brown University School of Public Health, Providence, Rhode Island, USA
| |
Collapse
|
26
|
Svarstad BL, Brown RL, Shireman TI. A successful intervention to improve medication adherence in Black patients with hypertension: Mediation analysis of 28-site TEAM trial. J Am Pharm Assoc (2003) 2022; 62:800-808.e3. [PMID: 35120864 PMCID: PMC9090964 DOI: 10.1016/j.japh.2022.01.002] [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: 10/03/2021] [Revised: 12/18/2021] [Accepted: 01/03/2022] [Indexed: 11/20/2022]
Abstract
BACKGROUND We previously reported the main effects and cost-effectiveness of a successful multifaceted Team Education and Adherence Monitoring (TEAM) intervention to improve refill adherence in Black patients with hypertension. It is important to identify the key mediators or intervention components that contributed to this intervention effect. OBJECTIVES This study aimed to conduct a "mediation analysis" to determine which intervention components had the largest effect on refill adherence and assess patient satisfaction with pharmacy care. METHODS A cluster-randomized trial was conducted among 576 Black patients in 28 pharmacies (14 TEAM, 14 control). TEAM participants were invited to 6 visits with a pharmacist-technician team that monitored the patient's blood pressure and used a 9-item Brief Medication Questionnaire, Brief Goal Check, and other novel tools to identify and reduce barriers to adherence in Black patients. Control participants received printed information only. Refill adherence was defined as >80% days covered (proportion of days covered) per refill records during months 7 to 12 (postintervention); potential mediators and patient satisfaction were assessed using a research questionnaire administered at month 6. A structural probit model examined 4 potential mediators that might explain intervention success. RESULTS Of 4 potential mediators, the most important factors in explaining the improvement in refill adherence (postintervention) were greater pharmacist collaboration with patient in barrier reduction (68.5% of total indirect effect) and patient use of a pillbox (27.2% of total indirect effect). Pharmacist contact with physician and suggestion of a change in regimen did not have significant effects on adherence. TEAM participants were more likely than control participants to rate their pharmacist care as "very satisfactory" (80.2% vs. 44.2%, P < 0.001) and technician care as "very satisfactory" (81.2% vs. 47.4%, P < 0.001). CONCLUSION Refill adherence and satisfaction can be improved in Black patients with hypertension by implementing a collaborative TEAM model with novel tools that enable community pharmacists and technicians to help identify and reduce the core barriers to adherence. Our results can be used to individualize and improve patient care and adherence outcomes in this vulnerable population.
Collapse
Affiliation(s)
- Bonnie L. Svarstad
- Professor Emerita, School of Pharmacy, University of Wisconsin – Madison, Madison, WI
| | - Roger L. Brown
- Professor, Schools of Nursing and Medicine, University of Wisconsin – Madison, Madison, WI
| | - Theresa I. Shireman
- Professor, Health Services Policy and Practice, Brown University School of Public Health, Providence, RI
| |
Collapse
|
27
|
Zhang T, Wilson IB, Zullo AR, Meyers DJ, Lee Y, Daiello LA, Kim DH, Kiel DP, Shireman TI, Berry SD. Hip Fracture Rates in Nursing Home Residents With and Without HIV. J Am Med Dir Assoc 2022; 23:517-518. [PMID: 34582781 PMCID: PMC8938961 DOI: 10.1016/j.jamda.2021.08.040] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2021] [Revised: 08/27/2021] [Accepted: 08/28/2021] [Indexed: 11/21/2022]
Affiliation(s)
- Tingting Zhang
- Department of Health Services, Policy & Practice, Brown University School of Public Health, Providence, RI, USA.
| | - Ira B Wilson
- Department of Health Services, Policy & Practice, Brown University School of Public Health, Providence, RI, USA
| | - Andrew R Zullo
- Department of Health Services, Policy & Practice, Brown University School of Public Health, Providence, RI, USA
| | - David J Meyers
- Department of Health Services, Policy & Practice, Brown University School of Public Health, Providence, RI, USA
| | - Yoojin Lee
- Department of Health Services, Policy & Practice, Brown University School of Public Health, Providence, RI, USA
| | - Lori A Daiello
- Department of Health Services, Policy & Practice, Brown University School of Public Health, Providence, RI, USA
| | - Dae Hyun Kim
- Hebrew SeniorLife, Hinda and Arthur Marcus Institute for Aging Research & Beth Israel Deaconess Medical Center, Department of Medicine, Harvard Medical School, 1200 Centre Street, Boston, MA, USA
| | - Douglas P Kiel
- Hebrew SeniorLife, Hinda and Arthur Marcus Institute for Aging Research & Beth Israel Deaconess Medical Center, Department of Medicine, Harvard Medical School, 1200 Centre Street, Boston, MA, USA
| | - Theresa I Shireman
- Department of Health Services, Policy & Practice, Brown University School of Public Health, Providence, RI, USA
| | - Sarah D Berry
- Hebrew SeniorLife, Hinda and Arthur Marcus Institute for Aging Research & Beth Israel Deaconess Medical Center, Department of Medicine, Harvard Medical School, 1200 Centre Street, Boston, MA, USA
| |
Collapse
|
28
|
Kapoor A, Patel J, Chen Z, Crawford S, McManus D, Gurwitz J, Shireman TI, Zhang N. Geriatric conditions do not predict stroke or bleeding in long-term care residents with atrial fibrillation. J Am Geriatr Soc 2021; 70:1218-1227. [PMID: 34902164 DOI: 10.1111/jgs.17605] [Citation(s) in RCA: 2] [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] [Subscribe] [Scholar Register] [Received: 06/25/2021] [Revised: 11/05/2021] [Accepted: 11/13/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND Long-term care (LTC) providers prescribe anticoagulation (AC) less frequently in residents with atrial fibrillation (AF) and geriatric conditions independent of CHA2 DS2 -VASc stroke risk score. Geriatric conditions include recent fall, activities of daily living dependency, mobility impairment, cognitive impairment, low body mass index, and weight loss. Multiple publications have suggested that patients with geriatric conditions are at increased risk for stroke. Understanding better the risk of stroke and bleeding in residents with AF and geriatric conditions would be valuable to LTC providers for AC decision-making. METHODS AND RESULTS We measured the association of geriatric conditions with composite of stroke/transient ischemic attack (TIA)/systemic embolism and bleeding in residents with AF and elevated stroke risk (CHA2 DS2 -VASc score ≥ 2) living in American LTC facilities in 2015. After merging nursing home assessments (Minimum Data Set) with medication and hospital utilization records, we identified 209,413 eligible residents. Using generalized estimating equations, we found that the incidence of stroke/TIA/systemic embolism ranged from 0.13% to 0.26% over 30 days (1.43%-3.08%/year) in residents off AC with and without geriatric conditions adjusting for other resident characteristics including CHA2 DS2 -VASc score and propensity to receive AC. Similarly, the monthly incidence of bleeding on AC ranged from 0.22% to 0.28% (2.61%-3.31%/year) without increased risk with geriatric conditions. Residents with a CHA2 DS2 -VASc score of ≥7 had a 2.4-fold increased risk of stroke compared with those with score of 2-4 (0.30% vs. 0.12%/month). CONCLUSION Calculating a CHA2 DS2 -VASc score can be helpful in AC decision-making for residents with and without geriatric conditions.
Collapse
Affiliation(s)
- Alok Kapoor
- Meyers Primary Care Institute, A Joint Endeavor of University of Massachusetts Medical School, Reliant Medical Group, and Fallon Health, Worcester, Massachusetts, USA.,Department of Medicine, University of Massachusetts Chan Medical School, Worcester, Massachusetts, USA
| | - Jay Patel
- Department of Medicine, University of Massachusetts Chan Medical School, Worcester, Massachusetts, USA
| | - Zhiyong Chen
- Department of Medicine, University of Massachusetts Chan Medical School, Worcester, Massachusetts, USA.,Zem Data Science, LLC, North Potomac, Maryland, USA
| | - Sybil Crawford
- Meyers Primary Care Institute, A Joint Endeavor of University of Massachusetts Medical School, Reliant Medical Group, and Fallon Health, Worcester, Massachusetts, USA.,Department of Medicine, University of Massachusetts Chan Medical School, Worcester, Massachusetts, USA
| | - David McManus
- Meyers Primary Care Institute, A Joint Endeavor of University of Massachusetts Medical School, Reliant Medical Group, and Fallon Health, Worcester, Massachusetts, USA.,Department of Medicine, University of Massachusetts Chan Medical School, Worcester, Massachusetts, USA
| | - Jerry Gurwitz
- Meyers Primary Care Institute, A Joint Endeavor of University of Massachusetts Medical School, Reliant Medical Group, and Fallon Health, Worcester, Massachusetts, USA.,Department of Medicine, University of Massachusetts Chan Medical School, Worcester, Massachusetts, USA
| | - Theresa I Shireman
- Department of Health Services, Policy and Practice, Center for Gerontology & Healthcare Research, School of Public Health, Brown University, Providence, Rhode Island, USA
| | - Ning Zhang
- Meyers Primary Care Institute, A Joint Endeavor of University of Massachusetts Medical School, Reliant Medical Group, and Fallon Health, Worcester, Massachusetts, USA.,Department of Health Policy and Promotion, School of Public Health and Health Sciences, University of Massachusetts Amherst, Amherst, Massachusetts, USA
| |
Collapse
|
29
|
Fashaw-Walters SA, McCreedy E, Bynum JPW, Thomas KS, Shireman TI. Disproportionate increases in schizophrenia diagnoses among Black nursing home residents with ADRD. J Am Geriatr Soc 2021; 69:3623-3630. [PMID: 34590709 DOI: 10.1111/jgs.17464] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2021] [Revised: 06/04/2021] [Accepted: 06/26/2021] [Indexed: 11/26/2022]
Abstract
BACKGROUND Previous research demonstrated an increase in the reporting of schizophrenia diagnoses among nursing home (NH) residents after the Centers for Medicare & Medicaid Services National Partnership to Improve Dementia Care. Given known health and healthcare disparities among Black NH residents, we examined how race and Alzheimer's and related dementia (ADRD) status influenced the rate of schizophrenia diagnoses among NH residents following the partnership. METHODS We used a quasi-experimental difference-in-differences design to study the quarterly prevalence of schizophrenia among US long-stay NH residents aged 65 years and older, by Black race and ADRD status. Using 2011-2015 Minimum Data Set 3.0 assessments, our analysis controlled for age, sex, measures of function and frailty (activities of daily living [ADL] and Changes in Health, End-stage disease and Symptoms and Signs scores) and behavioral expressions. RESULTS There were over 1.2 million older long-stay NH residents, annually. Schizophrenia diagnoses were highest among residents with ADRD. Among residents without ADRD, Black residents had higher rates of schizophrenia diagnoses compared to their nonblack counterparts prior to the partnership. Following the partnership, Black residents with ADRD had a significant increase of 1.7% in schizophrenia as compared to nonblack residents with ADRD who had a decrease of 1.7% (p = 0.007). CONCLUSIONS Following the partnership, Black NH residents with ADRD were more likely to have a schizophrenia diagnosis documented on their MDS assessments, and schizophrenia rates increased for Black NH residents with ADRD only. Further work is needed to examine the impact of "colorblind" policies such as the partnership and to determine if schizophrenia diagnoses are appropriately applied in NH practice, particularly for black Americans with ADRD.
Collapse
Affiliation(s)
- Shekinah A Fashaw-Walters
- Division of Health Policy & Management, School of Public Health, University of Minnesota, Minneapolis, Minnesota, USA.,Center for Gerontology and Healthcare Research, School of Public Health, Brown University, Providence, Rhode Island, USA.,Department of Health Services, Policy, and Practice, School of Public Health, Brown University, Providence, Rhode Island, USA
| | - Ellen McCreedy
- Center for Gerontology and Healthcare Research, School of Public Health, Brown University, Providence, Rhode Island, USA.,Department of Health Services, Policy, and Practice, School of Public Health, Brown University, Providence, Rhode Island, USA
| | - Julie P W Bynum
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, Michigan, USA.,Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Kali S Thomas
- Center for Gerontology and Healthcare Research, School of Public Health, Brown University, Providence, Rhode Island, USA.,Department of Health Services, Policy, and Practice, School of Public Health, Brown University, Providence, Rhode Island, USA.,Center of Innovation in Long-Term Services and Supports, U.S. Department of Veterans Affairs Medical Center, Providence, Rhode Island, USA
| | - Theresa I Shireman
- Center for Gerontology and Healthcare Research, School of Public Health, Brown University, Providence, Rhode Island, USA.,Department of Health Services, Policy, and Practice, School of Public Health, Brown University, Providence, Rhode Island, USA
| |
Collapse
|
30
|
Hughes L, Shireman TI, Hughto J. Privately Insured Transgender People Are At Elevated Risk For Chronic Conditions Compared With Cisgender Counterparts. Health Aff (Millwood) 2021; 40:1440-1448. [PMID: 34519545 DOI: 10.1377/hlthaff.2021.00546] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
The burden of morbidity among privately insured transgender people is largely unknown. We identified transgender people enrolled in private insurance (using claims from 2001-19) and compared their rates of selected chronic conditions, using the Elixhauser Comorbidity Index, with claims for a matched cisgender cohort. We documented disparities between transgender and cisgender people across most conditions and found that transgender people were at elevated risk for nearly all chronic conditions compared with their cisgender counterparts. We also found that trans masculine and nonbinary people had the highest predicted average number of chronic conditions compared with all other gender groups. Our findings highlight key gender differences in morbidity between and within transgender and cisgender populations, and they underscore the importance of collecting gender identity information in national surveillance efforts to increase understanding of the health disparities among transgender and cisgender populations. In addition, these findings underscore the need for nondiscrimination protections for transgender people in the US.
Collapse
Affiliation(s)
- Landon Hughes
- Landon Hughes is a doctoral candidate in the Department of Health Behavior and Health Education and a predoctoral trainee in the Population Studies Center, Institute for Social Research, University of Michigan, in Ann Arbor, Michigan
| | - Theresa I Shireman
- Theresa I. Shireman is a professor in the Department of Health Services, Policy, and Practice and director of the Center for Gerontology and Healthcare Research, Brown University School of Public Health, in Providence, Rhode Island
| | - Jaclyn Hughto
- Jaclyn Hughto is an assistant professor in the Departments of Behavioral and Social Sciences and Epidemiology and the Center for Health Promotion and Health Equity, Brown University School of Public Health. She is also an adjunct investigator at the Fenway Institute, Fenway Health, in Boston, Massachusetts
| |
Collapse
|
31
|
Jain N, Phadnis MA, Hunt SL, Dai J, Shireman TI, Davis CL, Mehta JL, Rasu RS, Hedayati SS. Comparative Effectiveness and Safety of Oral P2Y12 Inhibitors in Patients on Chronic Dialysis. Kidney Int Rep 2021; 6:2381-2391. [PMID: 34514199 PMCID: PMC8418979 DOI: 10.1016/j.ekir.2021.06.031] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2021] [Revised: 06/22/2021] [Accepted: 06/28/2021] [Indexed: 11/16/2022] Open
Abstract
Introduction Although oral P2Y12 inhibitors (P2Y12-Is) are one of the most commonly prescribed medication classes in patients with end stage kidney disease on dialysis (ESKD), scarce data exist regarding their benefits and risks. Methods We compared effectiveness and safety of clopidogrel, prasugrel, and ticagrelor in a longitudinal study using the United States Renal Data System registry of Medicare beneficiaries with ESKD. Individuals who filled new P2Y12-I prescriptions between 2011 and 2015 were included and followed until death or censoring. The primary exposure variable was P2Y12-I assignment. The primary outcome variable was death. Secondary outcomes included cardiovascular (CV) death, coronary revascularization, and gastrointestinal (GI) hemorrhage. Survival analyses were performed after propensity matching. Results Of 44,619 patients with ESKD who received P2Y12-Is, 95% received clopidogrel (n = 42,523), 3% prasugrel (n = 1205), and 2% ticagrelor (n = 891). To balance baseline differences, propensity-matching was performed: 1:6 for prasugrel (n = 1189) versus clopidogrel (n = 7134); 1:4 for ticagrelor (n = 880) versus clopidogrel (n = 3520); and 1:1 for ticagrelor versus prasugrel (n = 880). Prasugrel was associated with a reduced risk for death versus clopidogrel and ticagrelor (adjusted hazard ratio [HR] = 0.82; 95% CI: 0.73–0.93 and 0.78; 95% CI: 0.64–0.95). Compared with clopidogrel, prasugrel reduced risk for coronary revascularization (HR = 0.91; 95% CI: 0.86–0.96). There were no differences in GI hemorrhage between P2Y12-Is. Conclusion In patients with ESKD, prasugrel compared with others reduced risk of death possibly by reducing risk for coronary revascularizations and without worsening gastrointestinal hemorrhage. Future trials are imperative to compare efficacy and safety of P2Y12-Is in patients with ESKD.
Collapse
Affiliation(s)
- Nishank Jain
- Department of Internal Medicine, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA.,Medicine Service, Central Arkansas Veterans Affairs Medical Center, Little Rock, Arkansas, USA
| | - Milind A Phadnis
- Department of Biostatistics and Data Science, University of Kansas School of Medicine, Kansas City, Kansas, USA
| | - Suzanne L Hunt
- Department of Biostatistics and Data Science, University of Kansas School of Medicine, Kansas City, Kansas, USA
| | - Junqiang Dai
- Department of Biostatistics and Data Science, University of Kansas School of Medicine, Kansas City, Kansas, USA
| | - Theresa I Shireman
- Department of Health Services, Policy and Practice, School of Public Health, Brown University, Providence, Rhode Island, USA
| | - Clayton L Davis
- Department of Internal Medicine, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA
| | - Jawahar L Mehta
- Department of Internal Medicine, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA.,Medicine Service, Central Arkansas Veterans Affairs Medical Center, Little Rock, Arkansas, USA
| | - Rafia S Rasu
- Department of Pharmacotherapy, College of Pharmacy, University of North Texas Health Sciences, Fort Worth, Texas, USA
| | - S Susan Hedayati
- Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| |
Collapse
|
32
|
Murphy SM, Laiteerapong N, Pho MT, Ryan D, Montoya I, Shireman TI, Huang E, McCollister KE. Health economic analyses of the justice community opioid innovation network (JCOIN). J Subst Abuse Treat 2021; 128:108262. [PMID: 33419602 PMCID: PMC8255321 DOI: 10.1016/j.jsat.2020.108262] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [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] [Received: 09/05/2020] [Revised: 12/01/2020] [Accepted: 12/14/2020] [Indexed: 02/04/2023]
Abstract
The Justice Community Opioid Innovation Network (JCOIN) will generate real-world evidence to address the unique needs of people with opioid use disorder (OUD) in justice settings. Evidence regarding the economic value of OUD interventions in justice populations is limited. Moreover, the variation in economic study designs is a barrier to defining specific interventions as broadly cost-effective. The JCOIN Health Economics Analytic Team (HEAT) has worked closely with the Measures Committee to incorporate common economic measures and instruments across JCOIN studies, which will: a) ensure rigorous economic evaluations within each trial; b) enhance comparability of findings across studies; and c) allow for cross-study analyses of trials with similar designs/settings (e.g., pre-reentry MOUD), to assess questions beyond the scope of a single study, while controlling for and evaluating the effect of intervention-, organizational-, and population-level characteristics. We describe shared trial characteristics relevant to the economic evaluations, and discuss potential cross-study economic analyses.
Collapse
Affiliation(s)
- Sean M Murphy
- Department of Population Health Sciences, Weill Cornell Medical College, New York, NY, USA.
| | | | - Mai T Pho
- University of Chicago, Chicago, IL, USA
| | - Danielle Ryan
- Department of Population Health Sciences, Weill Cornell Medical College, New York, NY, USA
| | - Iván Montoya
- Department of Public Health Sciences, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Theresa I Shireman
- Health Services, Policy & Practice, Brown University School of Public Health, Providence, RI, USA
| | | | - Kathryn E McCollister
- Department of Public Health Sciences, University of Miami Miller School of Medicine, Miami, FL, USA
| |
Collapse
|
33
|
Zhang N, Patel J, Chen Z, Zhou Y, Crawford S, McManus DD, Gurwitz J, Shireman TI, Kapoor A. Geriatric Conditions Are Associated With Decreased Anticoagulation Use in Long-Term Care Residents With Atrial Fibrillation. J Am Heart Assoc 2021; 10:e021293. [PMID: 34387127 PMCID: PMC8475043 DOI: 10.1161/jaha.121.021293] [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] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background Anticoagulation is the mainstay for stroke prevention in patients with atrial fibrillation, but concerns about bleeding inhibit its use in residents of long‐term care facilities. Risk‐profiling algorithms using comorbid disease information (eg, CHADS2 and ATRIA [Anticoagulation and Risk Factors in Atrial Fibrillation]) have been available for years. In the long‐term care setting, however, providers and residents may place more value on geriatric conditions such as mobility impairment, activities of daily living dependency, cognitive impairment, low body mass index, weight loss, and fall history. Methods and Results Using a retrospective cohort design, we measured the association between geriatric conditions and anticoagulation use and type. After merging nursing home assessments containing information about geriatric conditions (Minimum Data Set 2015) with Medicare Part A 2014 to 2015 claims and prescription claims (Medicare Part D) 2015 to 2016, we identified 228 741 residents with atrial fibrillation and elevated stroke risk (CHA2DS2‐VASc score ≥2) for our main analysis. Recent fall, activities of daily living dependency, moderate and severe cognitive impairment, low body mass index, and unintentional weight loss were all associated with lower anticoagulation use even after adjustment for multiple predictors of stroke and bleeding (odds ratios ranging from 0.51 to 0.91). Residents with recent fall, low body mass index, and unintentional weight loss were more likely to be using a direct oral anticoagulant, although the magnitude of this effect was smaller. Conclusions Geriatric conditions were associated with lower anticoagulation use. Preventing stroke in these residents with potential for further physical and cognitive impairment would appear to be of paramount significance, although the net benefit of anticoagulation in these individuals warrants further research.
Collapse
Affiliation(s)
- Ning Zhang
- Meyers Primary Care Institute a joint endeavor of University of Massachusetts Medical SchoolReliant Medical Group, and Fallon Health Worcester MA.,Department of Health Policy and Promotion School of Public Health and Health Sciences University of Massachusetts Amherst Amherst MA
| | - Jay Patel
- University of Massachusetts Medical School Worcester MA
| | - Zhiyong Chen
- University of Massachusetts Medical School Worcester MA.,Zem Data Science North Potomac MD
| | - Yanhua Zhou
- Meyers Primary Care Institute a joint endeavor of University of Massachusetts Medical SchoolReliant Medical Group, and Fallon Health Worcester MA.,University of Massachusetts Medical School Worcester MA
| | - Sybil Crawford
- Meyers Primary Care Institute a joint endeavor of University of Massachusetts Medical SchoolReliant Medical Group, and Fallon Health Worcester MA.,University of Massachusetts Medical School Worcester MA
| | - David D McManus
- Meyers Primary Care Institute a joint endeavor of University of Massachusetts Medical SchoolReliant Medical Group, and Fallon Health Worcester MA.,University of Massachusetts Medical School Worcester MA
| | - Jerry Gurwitz
- Meyers Primary Care Institute a joint endeavor of University of Massachusetts Medical SchoolReliant Medical Group, and Fallon Health Worcester MA.,University of Massachusetts Medical School Worcester MA
| | - Theresa I Shireman
- Department of Health Services, Policy and Practice Center for Gerontology & Healthcare Research School of Public Health Brown University Providence RI
| | - Alok Kapoor
- Meyers Primary Care Institute a joint endeavor of University of Massachusetts Medical SchoolReliant Medical Group, and Fallon Health Worcester MA.,University of Massachusetts Medical School Worcester MA
| |
Collapse
|
34
|
Haubrick KK, Gadbois EA, Campbell SE, Young J, Zhang T, Rizvi S, Shireman TI, Shield RR. The Lived Experiences of Adults with Multiple Sclerosis. R I Med J (2013) 2021; 104:38-42. [PMID: 34323878] [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] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Abstract
Multiple sclerosis (MS), a chronic, often disabling, nervous system disease, affects over 2.3 million people worldwide. This research examined the lived experiences of 46 community-dwelling adults with MS. We conducted five focus groups that covered topics such as diagnosis, decision-making regarding MS treatment, learning about and paying for assistance, and unmet needs. Focus group transcripts were qualitatively analyzed to identify overarching themes. Participants described how MS affects both current and future physical and financial security, how they often feel unheard or misunderstood by loved ones and healthcare providers, and how MS support organizations provide a vital collaborative and compassionate environment. Our findings reflect the importance of MS support organizations, and the incorporation of social workers in MS care teams, as they can foster communication and empathy between parties, provide psycho- social treatment, and link patients to needed services.
Collapse
Affiliation(s)
- Kayla K Haubrick
- Brown University, Center for Gerontology and Healthcare Research
| | - Emily A Gadbois
- Brown University, Center for Gerontology and Healthcare Research
| | - Susan E Campbell
- Brown University, Center for Gerontology and Healthcare Research
| | | | - Tingting Zhang
- Brown University, Center for Gerontology and Healthcare Research
| | - Syed Rizvi
- Rhode Island Hospital, Multiple Sclerosis Center & Brown University Warren Alpert Medical School, Neurology
| | | | - Renee R Shield
- Brown University, Center for Gerontology and Healthcare Research
| |
Collapse
|
35
|
Zhang T, Wilson IB, Youn B, Lee Y, Shireman TI. Use of Antiretroviral Therapy for a US Medicaid Enrolled Pediatric Cohort with HIV. AIDS Behav 2021; 25:2455-2462. [PMID: 33665750 PMCID: PMC10754020 DOI: 10.1007/s10461-021-03208-w] [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] [Accepted: 02/20/2021] [Indexed: 10/22/2022]
Abstract
Appropriate antiretroviral therapy use in children with Human Immunodeficiency Virus (HIV) is essential for optimizing clinical outcomes and preventing HIV transmission. To describe and determine correlates of HIV antiretroviral therapy (ART) persistence and implementation for children and adolescents in the United States. We studied Medicaid enrollees (ages 2-19 years) with HIV in 14 states in 2011 and 2012. We defined non-persistence as a discontinuation of an ART regimen for at least 90 days, and calculated implementation as the proportion of days on ART while persistent. We used Cox proportional regression and logistic regression to determine characteristics associated with ART non-persistence and poor (< 90%) implementation, respectively. Among those with ≥ 1 year of observation (n = 8679), 55.7% never received ART. For ART recipients (n = 3849), 34.9% discontinued ART. Correlates of ART non-persistence included older age (e.g., 15-19 vs. 2-5 years [adjusted hazard ratio (aHR) 2.9, 95% CI 2.1-4.0]; females vs. males (aHR 1.2; 1.1-1.3); mental health conditions (aHR 1.3; 1.1-1.5), drug/alcohol abuse (aHR 1.2; 1.0-1.5) and HIV-related conditions (aHR 1.2; 1.0-1.4). Those with an outpatient visit were less likely to discontinue an ART (aHR 0.32; 0.28-0.36). During persistent episodes, 42.3% had poor ART implementation. Correlates of poor implementation included females vs. males (aOR 1.2; 95% CI 1.0-1.3), Black vs. White race (aOR 1.3; 95% CI 1.1-1.7) and Hispanic/Latino vs. White (aOR 1.3; 1.0-1.8). Among Medicaid youth with HIV, there were low rates of ART exposure, and ART discontinuation was common. Correlates of persistence and implementation differed, suggesting a need for varying clinical interventions to improve connection to care and ensuring ongoing engagement with ART use.
Collapse
Affiliation(s)
- Tingting Zhang
- Department of Health Services, Policy & Practice, Brown University School of Public Health, 121 South Main Street, Providence, Rhode Island, 02903, USA.
| | - Ira B Wilson
- Department of Health Services, Policy & Practice, Brown University School of Public Health, 121 South Main Street, Providence, Rhode Island, 02903, USA
| | - Bora Youn
- Department of Health Services, Policy & Practice, Brown University School of Public Health, 121 South Main Street, Providence, Rhode Island, 02903, USA
| | - Yoojin Lee
- Department of Health Services, Policy & Practice, Brown University School of Public Health, 121 South Main Street, Providence, Rhode Island, 02903, USA
| | - Theresa I Shireman
- Department of Health Services, Policy & Practice, Brown University School of Public Health, 121 South Main Street, Providence, Rhode Island, 02903, USA
| |
Collapse
|
36
|
Appaneal HJ, Shireman TI, Lopes VV, Mor V, Dosa DM, LaPlante KL, Caffrey AR. Poor clinical outcomes associated with suboptimal antibiotic treatment among older long-term care facility residents with urinary tract infection: a retrospective cohort study. BMC Geriatr 2021; 21:436. [PMID: 34301192 PMCID: PMC8299613 DOI: 10.1186/s12877-021-02378-5] [Citation(s) in RCA: 6] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2021] [Accepted: 06/25/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Antibiotic use is associated with several antibiotic-related harms in vulnerable, older long-term care (LTC) residents. Suboptimal antibiotic use may also be associated with harms but has not yet been investigated. The aim of this work was to compare rates of poor clinical outcomes among LTC residents with UTI receiving suboptimal versus optimal antibiotic treatment. METHODS We conducted a retrospective cohort study among residents with an incident urinary tract infection (UTI) treated in Veterans Affairs LTC units (2013-2018). Potentially suboptimal antibiotic treatment was defined as use of a suboptimal initial antibiotic drug choice, dose frequency, and/or excessive treatment duration. The primary outcome was time to a composite measure of poor clinical outcome, defined as UTI recurrence, acute care hospitalization/emergency department visit, adverse drug event, Clostridioides difficile infection (CDI), or death within 30 days of antibiotic discontinuation. Shared frailty Cox proportional hazard regression models were used to compare the time-to-event between suboptimal and optimal treatment. RESULTS Among 19,701 LTC residents with an incident UTI, 64.6% received potentially suboptimal antibiotic treatment and 35.4% experienced a poor clinical outcome. In adjusted analyses, potentially suboptimal antibiotic treatment was associated with a small increased hazard of poor clinical outcome (aHR 1.06, 95% CI 1.01-1.11) as compared with optimal treatment, driven by an increased hazard of CDI (aHR 1.94, 95% CI 1.54-2.44). CONCLUSION In this national cohort study, suboptimal antibiotic treatment was associated with a 6% increased risk of the composite measure of poor clinical outcomes, in particular, a 94% increased risk of CDI. Beyond the decision to use antibiotics, clinicians should also consider the potential harms of suboptimal treatment choices with regards to drug type, dose frequency, and duration used.
Collapse
Affiliation(s)
- Haley J Appaneal
- Infectious Diseases Research Program, Providence Veterans Affairs Medical Center, 830 Chalkstone Ave, Providence, RI, 02908, USA. .,Center of Innovation in Long-Term Support Services, Providence Veterans Affairs Medical Center, Providence, RI, USA. .,College of Pharmacy, University of Rhode Island, Kingston, RI, USA. .,Center for Gerontology & Health Care Research and Department of Health Services Policy & Practice, Brown University School of Public Health, Providence, RI, USA.
| | - Theresa I Shireman
- Center for Gerontology & Health Care Research and Department of Health Services Policy & Practice, Brown University School of Public Health, Providence, RI, USA
| | - Vrishali V Lopes
- Infectious Diseases Research Program, Providence Veterans Affairs Medical Center, 830 Chalkstone Ave, Providence, RI, 02908, USA
| | - Vincent Mor
- Center of Innovation in Long-Term Support Services, Providence Veterans Affairs Medical Center, Providence, RI, USA.,Center for Gerontology & Health Care Research and Department of Health Services Policy & Practice, Brown University School of Public Health, Providence, RI, USA
| | - David M Dosa
- Infectious Diseases Research Program, Providence Veterans Affairs Medical Center, 830 Chalkstone Ave, Providence, RI, 02908, USA.,Center of Innovation in Long-Term Support Services, Providence Veterans Affairs Medical Center, Providence, RI, USA.,College of Pharmacy, University of Rhode Island, Kingston, RI, USA.,Center for Gerontology & Health Care Research and Department of Health Services Policy & Practice, Brown University School of Public Health, Providence, RI, USA
| | - Kerry L LaPlante
- Infectious Diseases Research Program, Providence Veterans Affairs Medical Center, 830 Chalkstone Ave, Providence, RI, 02908, USA.,Center of Innovation in Long-Term Support Services, Providence Veterans Affairs Medical Center, Providence, RI, USA.,College of Pharmacy, University of Rhode Island, Kingston, RI, USA.,Division of Infectious Diseases, Warren Alpert Medical School of Brown University, Providence, RI, USA
| | - Aisling R Caffrey
- Infectious Diseases Research Program, Providence Veterans Affairs Medical Center, 830 Chalkstone Ave, Providence, RI, 02908, USA.,Center of Innovation in Long-Term Support Services, Providence Veterans Affairs Medical Center, Providence, RI, USA.,College of Pharmacy, University of Rhode Island, Kingston, RI, USA.,Center for Gerontology & Health Care Research and Department of Health Services Policy & Practice, Brown University School of Public Health, Providence, RI, USA
| |
Collapse
|
37
|
Erqou S, Jiang L, Choudhary G, Lally M, Freiberg M, Lin NH, Shireman TI, Rudolph JL, Wu WC. Age at Diagnosis of Heart Failure in United States Veterans With and Without HIV Infection. J Am Heart Assoc 2021; 10:e018983. [PMID: 33998245 PMCID: PMC8483515 DOI: 10.1161/jaha.120.018983] [Citation(s) in RCA: 2] [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] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Background Although HIV is associated with increased risk of heart failure (HF), it is not known if people living with HIV develop HF at a younger age compared with individuals without HIV. Crude comparisons of age at diagnosis of HF between individuals with and without HIV does not account for differences in underlying age structures between the populations. Methods and Results We used Veterans Health Administration data to compare the age at HF diagnosis between veterans with and without HIV, with adjustment for difference in population age structure. Statistical weights, calculated for each 1‐year strata of veterans with HIV in each calendar year from 2000 to 2018, were applied to the veterans without HIV to standardize the age structure. We identified 5093 veterans with HIV (98% men, 34% White) with first HF episode recorded after HIV diagnosis (median age at incidence of HF, 58 years), and 1 425 987 veterans without HIV (98% men, 78% White) with HF (corresponding age, 72 years), with an absolute difference of 14 years. After accounting for difference in age structure, the adjusted median age at HF diagnosis for veterans without HIV was 63 years, 5 years difference with veterans with HIV (P<0.001). The age differences were consistent across important subgroups such as preserved versus reduced ejection fraction and inpatient versus outpatient index HF. Conclusions Veterans with HIV are diagnosed with HF at a significantly younger age compared with veterans without HIV. These findings may have implications for HF prevention in individuals with HIV. Future studies are needed to make the findings more generalizable.
Collapse
Affiliation(s)
- Sebhat Erqou
- Department of Medicine Providence VA Medical Center Providence RI.,Center of Innovation in Long Term Services and Supports Providence VA Medical Center Providence RI.,Department of Medicine Alpert Medical School of Brown University Providence RI
| | - Lan Jiang
- Center of Innovation in Long Term Services and Supports Providence VA Medical Center Providence RI
| | - Gaurav Choudhary
- Department of Medicine Providence VA Medical Center Providence RI.,Department of Medicine Alpert Medical School of Brown University Providence RI
| | - Michelle Lally
- Department of Medicine Providence VA Medical Center Providence RI.,Department of Medicine Alpert Medical School of Brown University Providence RI
| | | | - Nina H Lin
- Department of Medicine Boston University Boston MA
| | | | - James L Rudolph
- Department of Medicine Providence VA Medical Center Providence RI.,Center of Innovation in Long Term Services and Supports Providence VA Medical Center Providence RI.,Department of Medicine Alpert Medical School of Brown University Providence RI.,Brown University School of Public Health Providence RI
| | - Wen-Chih Wu
- Department of Medicine Providence VA Medical Center Providence RI.,Center of Innovation in Long Term Services and Supports Providence VA Medical Center Providence RI.,Department of Medicine Alpert Medical School of Brown University Providence RI.,Brown University School of Public Health Providence RI
| |
Collapse
|
38
|
Davidson HE, Radlowski P, Han L, Shireman TI, Dembek C, Niu X, Gravenstein S. Clinical Characterization of Nursing Facility Residents With Chronic Obstructive Pulmonary Disease. Sr Care Pharm 2021; 36:248-257. [PMID: 33879286 DOI: 10.4140/tcp.n.2021.248] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
OBJECTIVE AND DESIGN To describe clinical characteristics, medication use, and low peak inspiratory flow rate (PIFR) (< 60 L/min) prevalence in nursing facility residents with chronic obstructive pulmonary disease (COPD). PATIENTS AND SETTING Residents 60 years of age and older with a COPD diagnosis and≥ 6 months' nursing facility residence, were enrolled between December 2017 and February 2019 from 26 geographically varied United States nursing facilities. OUTCOME MEASURES Data, extracted from residents' charts, included demographic/clinical characteristics, COPD-related medications, exacerbations and hospitalizations within the past 6 months, and functional status from the most recent Minimum Data Set. At enrollment, residents completed the modified Medical Research Council (mMRC) Dyspnea Scale and COPD Assessment Test (CAT™). Spirometry and PIFR were also assessed. RESULTS Residents' (N = 179) mean age was 78.0 ± 10.6 years, 63.7% were female, and 57.0% had low PIFR. Most prevalent comorbidities were hypertension (79.9%), depression (49.2%), and heart failure (41.9%). The average forced expiratory volume in 1 second (FEV11) % predicted was 45.9% ± 20.9%. On the CAT, 78.2% scored≥ 10 and on the mMRC Dyspnea Scale, 74.1% scored≥ 2, indicating most residents had high COPD symptom burden. Only 49.2% were receiving a scheduled long-acting bronchodilator (LABD). Among those with low PIFR prescribed a LABD, > 80% used dry powder inhalers for medication delivery. CONCLUSION This study highlights underutilization of scheduled LABD therapy in nursing facility residents with COPD. Low PIFR was prevalent in residents while the majority used suboptimal medication delivery devices. The findings highlight opportunities for improving management and outcomes for nursing facility residents with COPD.
Collapse
Affiliation(s)
| | | | - Lisa Han
- 1Insight Therapeutics, LLC, Norfolk, Virginia
| | - Theresa I Shireman
- 2Brown University, Center for Gerontology and Health Care Research, Providence, Rhode Island
| | - Carole Dembek
- 3Sunovion Pharmaceuticals, Incorporated, Marlborough, Massachusetts
| | - Xiaoli Niu
- 3Sunovion Pharmaceuticals, Incorporated, Marlborough, Massachusetts
| | - Stefan Gravenstein
- 2Brown University, Center for Gerontology and Health Care Research, Providence, Rhode Island
| |
Collapse
|
39
|
Gerlach LB, Park PS, Shireman TI, Bynum JPW. Changes in medication use among long-stay residents with dementia in Michigan during the pandemic. J Am Geriatr Soc 2021; 69:1743-1745. [PMID: 33834488 PMCID: PMC8251218 DOI: 10.1111/jgs.17161] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2021] [Accepted: 03/27/2021] [Indexed: 12/02/2022]
Affiliation(s)
- Lauren B Gerlach
- Department of Psychiatry, University of Michigan, Ann Arbor, Michigan, USA.,Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, Michigan, USA
| | - Pil S Park
- Institute of Gerontology, University of Michigan, Ann Arbor, Michigan, USA
| | - Theresa I Shireman
- Center for Gerontology and Healthcare Research, Brown University, Providence, Rhode Island, USA
| | - Julie P W Bynum
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, Michigan, USA.,Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
| |
Collapse
|
40
|
Gerlach LB, Fashaw S, Strominger J, Ogarek J, Zullo AR, Daiello LA, Teno J, Shireman TI, Bynum JPW. Trends in antipsychotic prescribing among long-term care residents receiving hospice care. J Am Geriatr Soc 2021; 69:2152-2162. [PMID: 33837537 DOI: 10.1111/jgs.17172] [Citation(s) in RCA: 2] [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] [Subscribe] [Scholar Register] [Received: 12/11/2020] [Revised: 03/09/2021] [Accepted: 03/22/2021] [Indexed: 11/30/2022]
Abstract
IMPORTANCE The Centers for Medicare & Medicaid Services' (CMS) National Partnership to Improve Dementia Care in Nursing Homes ("CMS National Partnership") focuses on reducing antipsychotic prescribing to long-term care residents. Hospice enrollment is not an exclusionary condition for the antipsychotic quality measure reported by CMS. It is unclear how prescribing in hospice may have been impacted by the initiative. OBJECTIVE Estimate the association of the CMS National Partnership with trends in antipsychotic prescribing among long-term care residents in hospice. DESIGN Interrupted time-series analysis of a 100% Minimum Data Set sample with linked hospice claims from 2011 to 2017. SETTING Long-term care nursing facilities. PARTICIPANTS Older adults ≥65 residing in long-term care (n = 3,741,379) and limited to those enrolled in hospice (n = 821,610). MAIN OUTCOME Quarterly prevalence of antipsychotic and other psychotropic (antianxiety, hypnotic, antidepressant) use among long-term care residents; overall and among residents with dementia, stratified by hospice enrollment. RESULTS From 2011 to 2017, parallel declines in antipsychotic prescribing were observed among long-term care residents enrolled and not enrolled in hospice (hospice: decline from 26.8% to 18.7%; non-hospice: decline from 23.0% to 14.4%). Following the 2012 CMS National Partnership, quarterly rates of antipsychotic prescribing declined significantly for both residents enrolled and not enrolled in hospice care. Declines in antipsychotic prescribing were greater for residents with dementia, with similar rates among residents enrolled and not enrolled in hospice. Among residents with dementia enrolled in hospice, use of other psychotropic medication classes including antianxiety, antidepressant, and hypnotic use remained relatively stable over time. CONCLUSIONS AND RELEVANCE Declines in antipsychotic prescribing during the CMS National Partnership occurred among long-term care residents in hospice, where use may be deemed clinically appropriate. Nursing homes are an important location for the provision of dementia end-of-life care and the drivers of potentially unintended reductions in antipsychotic use merits further investigation.
Collapse
Affiliation(s)
- Lauren B Gerlach
- Department of Psychiatry, University of Michigan, Ann Arbor, Michigan, USA.,Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, Michigan, USA
| | - Shekinah Fashaw
- Center for Gerontology and Healthcare Research, Brown University, Providence, Rhode Island, USA
| | - Julie Strominger
- Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, Michigan, USA
| | - Jessica Ogarek
- Center for Gerontology and Healthcare Research, Brown University, Providence, Rhode Island, USA
| | - Andrew R Zullo
- Center for Gerontology and Healthcare Research, Brown University, Providence, Rhode Island, USA
| | - Lori A Daiello
- Center for Gerontology and Healthcare Research, Brown University, Providence, Rhode Island, USA
| | - Joan Teno
- Department of Internal Medicine, Oregon Health and Sciences University, Portland, Oregon, USA
| | - Theresa I Shireman
- Center for Gerontology and Healthcare Research, Brown University, Providence, Rhode Island, USA
| | - Julie P W Bynum
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, Michigan, USA.,Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
| |
Collapse
|
41
|
Horace RW, Roberts M, Shireman TI, Merhi B, Jacques P, Bostom AG, Liu S, Eaton CB. Remnant cholesterol is prospectively associated with CVD events and all-cause mortality in kidney transplant recipients: the FAVORIT study. Nephrol Dial Transplant 2021; 37:382-389. [PMID: 33760035 DOI: 10.1093/ndt/gfab068] [Citation(s) in RCA: 2] [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] [Subscribe] [Scholar Register] [Received: 09/08/2020] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND The cholesterol content of circulating triglyceride-rich lipoproteins is characterized as remnant cholesterol, although little is known about its role in the development of CVD outcomes, all-cause mortality, or transplant failure in kidney transplant recipients. Our primary aim was to investigate the prospective association of remnant cholesterol and the risk of CVD events in renal transplant recipients with secondary aims evaluating remnant cholesterol and renal graft failure and all-cause mortality among participants in the Folic Acid for Vascular Outcome Reduction in Transplantation (FAVORIT) trial. METHODS Among 4,110 enrolled participants, 98 were excluded for missing baseline remnant cholesterol levels and covariates. Non fasting remnant cholesterol levels were calculated based upon lipid profiles in 3,812 FAVORIT trial participants at randomization. Wilcoxon-type test for trend were used to compare baseline characteristics across remnant cholesterol quartiles. Cox proportional hazards regression was used to evaluate the association of baseline remnant cholesterol levels with time to primary and secondary study outcomes. RESULTS During a median follow-up of 4.0 years, we documented 548 CVD incident events, 343 transplant failures, 452 All-Cause deaths. When comparing highest quartile 4 to quartile 1, proportional hazards modeling revealed a significant increase in CVD risk (HR, 1.32; 95% CI, 1.04-1.67) and all-cause mortality risk (HR, 1.34; 95% CI, 1.01-1.69). A non-significant increase in transplant failure was seen as well (HR, 1.20; 95% CI, 0.87-1.64). CONCLUSION Remnant cholesterol is associated with CVD and all-cause mortality in long-term kidney transplant recipients KTRs. A randomized controlled clinical trial in KTRs that assesses the potential impact of remnant cholesterol-lowering therapy on these outcomes may be warranted.
Collapse
Affiliation(s)
- Reuben William Horace
- Brown University School of Public Health, Department of Epidemiology, USA.,Center for Primary Care, Prevention, Brown University, Providence, RI, USA
| | - Mary Roberts
- Center for Primary Care, Prevention, Brown University, Providence, RI, USA
| | - Theresa I Shireman
- Brown University School of Public Health: Center for Gerontology and Healthcare Research, Brown University, Providence, RI, USA
| | - Basma Merhi
- Division of Hypertension and Kidney Diseases, Department of Medicine, Rhode Island Hospital, USA
| | - Paul Jacques
- Nutritional Epidemiology Program, USDA Human Nutrition Research Center on Aging, USA
| | - Andrew G Bostom
- Division of Hypertension and Kidney Diseases, Department of Medicine, USA
| | - Simin Liu
- Departments of Epidemiology and Medicine and Center for Global Cardiometabolic Health, USA
| | - Charles B Eaton
- Center for Primary Care, Prevention, Brown University, Providence, RI, USA
| |
Collapse
|
42
|
Zhang T, Wilson IB, Youn B, Lee Y, Shireman TI. Factors Associated With Antiretroviral Therapy Reinitiation in Medicaid Recipients With Human Immunodeficiency Virus. J Infect Dis 2021; 221:1607-1611. [PMID: 31840184 PMCID: PMC7184904 DOI: 10.1093/infdis/jiz666] [Citation(s) in RCA: 4] [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: 08/03/2019] [Accepted: 12/13/2019] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND This study was conducted to examine patient characteristics associated with antiretroviral therapy (ART) reinitiation in Medicaid enrollees. METHODS This is a retrospective cohort study that uses Cox proportional hazard regression to examine the association between person-level characteristics and time from ART discontinuation to the subsequent reinitiation within 18 months. RESULTS There were 45 409 patients who discontinued ART, and 44% failed to reinitiate. More outpatient visits (3+ vs 0 outpatient visits: adjusted hazard ratio (adjHR), 1.56; 99% confidence interval [CI], 1.45-1.67) and hospitalization (adjHR, 1.18; 99% CI,1.16-1.20) during follow-up were associated with reinitiation. CONCLUSIONS Failure to reinitiate ART within 18 months was common in this sample. Care engagement was associated with greater ART reinitiation.
Collapse
Affiliation(s)
- T Zhang
- Department of Health Services, Policy and Practice, Brown University School of Public Health, Providence, Rhode Island, USA
| | - I B Wilson
- Department of Health Services, Policy and Practice, Brown University School of Public Health, Providence, Rhode Island, USA
| | - B Youn
- Department of Health Services, Policy and Practice, Brown University School of Public Health, Providence, Rhode Island, USA
| | - Y Lee
- Department of Health Services, Policy and Practice, Brown University School of Public Health, Providence, Rhode Island, USA
| | - T I Shireman
- Department of Health Services, Policy and Practice, Brown University School of Public Health, Providence, Rhode Island, USA
| |
Collapse
|
43
|
Appaneal HJ, Caffrey AR, Lopes VV, Mor V, Dosa DM, LaPlante KL, Shireman TI. Predictors of potentially suboptimal treatment of urinary tract infections in long-term care facilities. J Hosp Infect 2021; 110:114-121. [PMID: 33549769 DOI: 10.1016/j.jhin.2021.01.019] [Citation(s) in RCA: 4] [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: 06/04/2020] [Revised: 01/15/2021] [Accepted: 01/15/2021] [Indexed: 12/20/2022]
Abstract
BACKGROUND Suboptimal antibiotic treatment of urinary tract infection (UTI) is high in long-term care facilities (LTCFs) and likely varies between facilities. Large-scale evaluations have not been conducted. AIM To identify facility-level predictors of potentially suboptimal treatment of UTI in Veterans Affairs (VA) LTCFs and to quantify variation across facilities. METHODS This was a retrospective cohort study of 21,938 residents in 120 VA LTCFs (2013-2018) known as Community Living Centers (CLCs). Potentially suboptimal treatment was assessed from drug choice, dose frequency, and/or treatment duration. To identify facility characteristics predictive of suboptimal UTI treatment, LTCFs with higher and lower rates of suboptimal treatment (≥median, < median) were compared using unconditional logistic regression models. Joinpoint regression models were used to quantify average percentage difference across facilities. Multilevel logistic regression models were used to quantify variation across facilities. FINDINGS The rate of potentially suboptimal antibiotic treatment varied from 1.7 to 34.2 per 10,000 bed-days across LTCFs. The average percentage difference in rates across facilities was 2.5% (95% confidence interval (CI): 2.4-2.7). The only facility characteristic predictive of suboptimal treatment was the incident rate of UTI per 10,000 bed-days (odds ratio: 4.9; 95% CI: 2.3-10.3). Multilevel models demonstrated that 94% of the variation between facilities was unexplained after controlling for resident and CLC characteristics. The median odds ratio for the full multilevel model was 1.37. CONCLUSION Potentially suboptimal UTI treatment was variable across VA LTCFs. However, most of the variation across LTCFs was unexplained. Future research should continue to investigate factors that are driving suboptimal antibiotic treatment in LTCFs.
Collapse
Affiliation(s)
- H J Appaneal
- Infectious Diseases Research Program, Providence Veterans Affairs Medical Center, Providence, RI, USA; Center of Innovation in Long-Term Support Services, Providence Veterans Affairs Medical Center, Providence, RI, USA; College of Pharmacy, University of Rhode Island, Kingston, RI, USA; Center for Gerontology & Health Care Research and Department of Health Services Policy & Practice, Brown University School of Public Health, Providence, RI, USA.
| | - A R Caffrey
- Infectious Diseases Research Program, Providence Veterans Affairs Medical Center, Providence, RI, USA; Center of Innovation in Long-Term Support Services, Providence Veterans Affairs Medical Center, Providence, RI, USA; College of Pharmacy, University of Rhode Island, Kingston, RI, USA; Center for Gerontology & Health Care Research and Department of Health Services Policy & Practice, Brown University School of Public Health, Providence, RI, USA
| | - V V Lopes
- Infectious Diseases Research Program, Providence Veterans Affairs Medical Center, Providence, RI, USA
| | - V Mor
- Center of Innovation in Long-Term Support Services, Providence Veterans Affairs Medical Center, Providence, RI, USA; Center for Gerontology & Health Care Research and Department of Health Services Policy & Practice, Brown University School of Public Health, Providence, RI, USA
| | - D M Dosa
- Infectious Diseases Research Program, Providence Veterans Affairs Medical Center, Providence, RI, USA; Center of Innovation in Long-Term Support Services, Providence Veterans Affairs Medical Center, Providence, RI, USA; Center for Gerontology & Health Care Research and Department of Health Services Policy & Practice, Brown University School of Public Health, Providence, RI, USA
| | - K L LaPlante
- Infectious Diseases Research Program, Providence Veterans Affairs Medical Center, Providence, RI, USA; Center of Innovation in Long-Term Support Services, Providence Veterans Affairs Medical Center, Providence, RI, USA; College of Pharmacy, University of Rhode Island, Kingston, RI, USA; Center for Gerontology & Health Care Research and Department of Health Services Policy & Practice, Brown University School of Public Health, Providence, RI, USA; Warren Alpert Medical School of Brown University, Division of Infectious Diseases, Providence, RI, USA
| | - T I Shireman
- Center for Gerontology & Health Care Research and Department of Health Services Policy & Practice, Brown University School of Public Health, Providence, RI, USA
| |
Collapse
|
44
|
Hughto JMW, Quinn EK, Dunbar MS, Rose AJ, Shireman TI, Jasuja GK. Prevalence and Co-occurrence of Alcohol, Nicotine, and Other Substance Use Disorder Diagnoses Among US Transgender and Cisgender Adults. JAMA Netw Open 2021; 4:e2036512. [PMID: 33538824 PMCID: PMC7862992 DOI: 10.1001/jamanetworkopen.2020.36512] [Citation(s) in RCA: 62] [Impact Index Per Article: 20.7] [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] [Indexed: 12/23/2022] Open
Abstract
IMPORTANCE Substance use disorders are a major source of morbidity and mortality in the United States. National data comparing the prevalence of substance use disorder diagnoses (SUDDs) among transgender and cisgender individuals are lacking in the United States. OBJECTIVES To investigate the prevalence of SUDDs among transgender and cisgender adults and to identify within-group and between-group differences by age, gender, and geographic location. DESIGN, SETTING, AND PARTICIPANTS This cross-sectional study used the OptumLabs Data Warehouse to analyze deidentified claims from approximately 74 million adults aged 18 years or older enrolled in commercial or Medicare Advantage insurance plans in 2017. A total of 15 637 transgender adults were identified based on a previously developed algorithm using a combination of International Classification of Diseases, Tenth Revision (ICD-10) transgender-related diagnosis and procedure codes and sex-discordant hormone prescriptions. A cohort of 46 911 cisgender adults was matched to the transgender cohort in a 3:1 ratio based on age and geographic location. MAIN OUTCOMES AND MEASURES SUDDs, based on ICD-10 codes, were assessed overall and compared between transgender and cisgender cohorts and by geographic region (ie, Northeast, Midwest, South, and West); age groups (eg, 18-25, 26-30, 31-35 years), and gender (ie, transfeminine [TF; assigned male sex at birth, identify along feminine gender spectrum], transmasculine [TM; assigned female sex at birth, identify along masculine gender spectrum], male, and female). RESULTS In this study of 15 637 transgender adults (4955 [31.7%] TM) and 46 911 cisgender adults (23 247 [50.4%] men), most (8627 transgender adults [55.2%]; 51 762 cisgender adults [55.2%]) were aged between 18 and 40 years, and 6482 transgender adults (41.5%) and 19 446 cisgender adults (41.5%) lived in the South. Comparing transgender to cisgender groups, significant differences were found in the prevalence of a nicotine (2594 [16.6%] vs 2551 [5.4%]; P < .001), alcohol (401 [2.6%] vs 438 [0.9%]; P < .001), and drug (678 [4.3%] vs 549 [1.2%]; P < .001) SUDDs. Among transgender adults, cannabis was the most prevalent drug SUDD (321 [2.1%]), followed by opioid SUDD (205 [1.3%]) and cocaine SUDD (81 [0.5%]), whereas among cisgender adults, cannabis and opioid SUDDs were equally prevalent (cannabis, 186 [0.4%]; opioid, 207 [0.4%]), followed by cocaine SUDD (59 [0.1%]). CONCLUSIONS AND RELEVANCE In this study, the prevalence of SUDDs was significantly elevated among transgender adults relative to their cisgender peers. These findings underscore the need for culturally tailored clinical interventions to treat substance use disorder in transgender populations.
Collapse
Affiliation(s)
- Jaclyn M. W. Hughto
- Department of Behavioral and Social Sciences, Brown University School of Public Health, Providence, Rhode Island
- Center for Health Promotion and Health Equity, Brown School of Public Health, Brown University, Providence, Rhode Island
- Department of Epidemiology, Brown University School of Public Health, Providence, Rhode Island
| | - Emily K. Quinn
- Biostatistics and Epidemiology Data Analytics Center, Boston University School of Public Health, Boston, Massachusetts
| | | | - Adam J. Rose
- School of Public Health, Hebrew University, Jerusalem, Israel
| | - Theresa I. Shireman
- Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, Rhode Island
- Center for Gerontology and Healthcare Research, Brown University, Providence, Rhode Island
| | - Guneet K. Jasuja
- Center for Healthcare Organization and Implementation Research, Edith Nourse Rogers Memorial Veterans Affairs Medical Center, Bedford, Massachusetts
- Department of Health Law, Policy, and Management, Boston University School of Public Health, Boston, Massachusetts
- OptumLabs, Eden Prairie, Minnesota
| |
Collapse
|
45
|
Jiang JJ, Adia AC, Nazareno J, Operario D, Ponce NA, Shireman TI. The Association Between Moderate and Serious Mental Health Distress and General Health Services Utilization Among Chinese, Filipino, Japanese, Korean, and Vietnamese Adults in California. J Racial Ethn Health Disparities 2021; 9:227-235. [PMID: 33452574 DOI: 10.1007/s40615-020-00946-w] [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] [Received: 09/05/2020] [Revised: 12/06/2020] [Accepted: 12/14/2020] [Indexed: 11/25/2022]
Abstract
INTRODUCTION A growing body of literature has indicated that disaggregated analyses using distinct Asian subgroups allow for identification of varying mental health challenges and health services utilization. In this study, we examined the associations between distress and health services utilization among five Asian subgroups: Chinese, Korean, Japanese, Filipino, and Vietnamese adults in California. MATERIALS AND METHODS Using a combined dataset using the 2011-2018 cross-sectional cycles of the California Health Interview survey, we assessed moderate and serious distress and four health services utilization indicators in a set of disaggregated analyses among adults 18 years of age and older in five Asian subgroups. We performed bivariate and multivariable analyses. RESULTS The prevalence of and associations between moderate and serious distress and gaps in health services utilization varied among each Asian subgroup. Koreans had the highest prevalence of moderate and serious distress and the most gaps in health services utilization. Compared to those without moderate distress (p < .05), Japanese adults were more likely to delay care. Compared to those without serious distress (p < .05), Chinese adults who experienced serious distress were more likely to delay both medications and care, whereas Filipino and Vietnamese adults were more likely to delay medications. DISCUSSION Disaggregating health data elucidates the impact of mental distress on healthcare-seeking behaviors among specific Asian subgroups. Identifying these influences can facilitate future tailored interventions, yet fully understanding the mechanism linking mental distress and healthcare usage will necessitate a comprehensive assessment of structural influences and Asian American experiences without otherization.
Collapse
Affiliation(s)
- Joy J Jiang
- Graduate School of Biomedical Sciences, Icahn School of Medicine at Mount Sinai, New York, USA
| | - Alexander C Adia
- Philippine Health Initiative for Research, Service, & Training, Brown University School of Public Health, Providence, RI, USA.
| | - Jennifer Nazareno
- Philippine Health Initiative for Research, Service, & Training, Brown University School of Public Health, Providence, RI, USA
| | - Don Operario
- Philippine Health Initiative for Research, Service, & Training, Brown University School of Public Health, Providence, RI, USA
| | - Ninez A Ponce
- UCLA Department of Health Policy and Management, Fielding School of Public Health, Los Angeles, CA, USA
- UCLA Center for Health Policy Research, Los Angeles, CA, USA
| | - Theresa I Shireman
- Center for Gerontology & Healthcare Research, Brown University School of Public Health, Providence, RI, USA
| |
Collapse
|
46
|
Kim DS, Jones RN, Shireman TI, Kluger BM, Friedman JH, Akbar U. Trends and outcomes associated with gastrostomy tube placement in common neurodegenerative disorders. Clin Park Relat Disord 2020; 4:100088. [PMID: 34316666 PMCID: PMC8299983 DOI: 10.1016/j.prdoa.2020.100088] [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] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2020] [Revised: 11/18/2020] [Accepted: 12/12/2020] [Indexed: 12/23/2022] Open
Abstract
INTRODUCTION Dysphagia causing aspiration pneumonia is a common complication in the advanced stages of neurodegenerative disorders. Historically, physicians attempted to prevent this complication with gastrostomy tube (GT) placement. Its use is supported in amyotrophic lateral sclerosis (ALS), not supported in Alzheimer's disease (AD), and without disease-specific guidelines in Parkinson's disease (PD). METHOD The rate of GT placement in these three populations over two decades, from 1990 to 2010, was calculated using a binomial regression model with the data extracted using diagnosis and procedural codes from a national database. The median length-of-stay (LOS) and discharge destinations were compared. RESULTS The rate of GT placement was 6.0% lower annually in AD, 3.4% in PD, and 0.2% in ALS (all p ≤ 0.007). The analysis of hospital LOS and discharge destination showed 3.2 to 5.5 days longer LOS with GT placement in all groups (all p ≤ 0.01), and three to four times lower odds of going home with GT placement in AD and PD groups (OR 0.28, 95% CI 0.14-0.55, and OR 0.22, CI 0.11-0.42 respectively), while unchanged in ALS group (OR 1.1, 95% CI 0.6-1.9). CONCLUSION Despite the downward trend of GT placement over two decades, thousands of AD and PD patients still underwent GT placement annually, and this was associated with longer LOS in all groups and increased likelihood of being discharged to a nursing facility in AD and PD. Further research is necessary to understand the effects of GT on physician practices and patient expectations in advanced AD and PD.
Collapse
Affiliation(s)
- Duk Soo Kim
- Brown University, Department of Neurology, Providence, RI, United States
- Rhode Island Hospital, Providence, RI, United States
| | - Richard N. Jones
- Brown University, Department of Neurology, Providence, RI, United States
- Brown University, Department of Psychiatry and Human Behavior, Providence, RI, United States
| | - Theresa I. Shireman
- Brown University, Department of Health Services, Policy & Practice, Providence, RI, United States
- Brown University, Center for Gerontology & Health Care Research, Providence, RI, United States
| | - Benzi M. Kluger
- University of Colorado, Department of Neurology, Aurora, CO, United States
| | - Joseph H. Friedman
- Brown University, Department of Neurology, Providence, RI, United States
- Butler Hospital, Providence, RI, United States
| | - Umer Akbar
- Brown University, Department of Neurology, Providence, RI, United States
- Rhode Island Hospital, Providence, RI, United States
- Butler Hospital, Providence, RI, United States
| |
Collapse
|
47
|
Wentz AE, Wang RRC, Marshall BDL, Shireman TI, Liu T, Merchant RC. Variation in opioid analgesia administration and discharge prescribing for emergency department patients with suspected urolithiasis. Am J Emerg Med 2020; 38:2119-2124. [PMID: 33071098 PMCID: PMC7704692 DOI: 10.1016/j.ajem.2020.07.016] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [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: 02/27/2020] [Revised: 07/03/2020] [Accepted: 07/03/2020] [Indexed: 02/08/2023] Open
Abstract
OBJECTIVE Previous research has suggested caution about opioid analgesic usage in the emergency department (ED) setting and raised concerns about variations in prescription opioid analgesic usage, both across institutions and for whom they are prescribed. We examined opioid analgesic usage in ED patients with suspected urolithiasis across fifteen participating hospitals. METHODS This is a secondary analysis of a clinical trial including adult ED patients with suspected urolithiasis. In multilevel models accounting for clustering by hospital, we assessed demographic, clinical, state-level, and hospital-level factors associated with opioid analgesic administration during the ED visit and prescription at discharge. RESULTS Of 2352 participants, 67% received an opioid analgesic during the ED visit and 61% were prescribed one at discharge. Opioid analgesic usage varied greatly across hospitals, ranging from 46% to 88% (during visit) and 34% to 85% (at discharge). Hispanic patients were less likely than non-Hispanic white patients to receive opioid analgesics during the ED visit (OR 0.72, 95% CI 0.55-0.94). Patients with higher education (OR 1.29, 95% CI 1.05-1.59), health insurance coverage (OR 1.27, 95% CI 1.02-1.60), or receiving care in states with a prescription drug monitoring program (OR 1.64, 95% CI 1.06-2.53) were more likely to receive an opioid analgesic prescription at ED discharge. CONCLUSION We found marked hospital-level differences in opioid analgesic administration and prescribing, as well as associations with education, healthcare insurance, and race/ethnicity groups. These data might compel clinicians and hospitals to examine their opioid use practices to ensure it is congruent with accepted medical practice.
Collapse
Affiliation(s)
- Anna E Wentz
- Brown University School of Public Health, Department of Epidemiology, Box G-121-3, Providence, RI 02912, USA.
| | - Ralph R C Wang
- Emergency Medicine, University of California, San Francisco, San Francisco, CA, USA.
| | - Brandon D L Marshall
- Brown University School of Public Health, Department of Epidemiology, Providence, RI, USA.
| | - Theresa I Shireman
- Brown University School of Public Health, Health Services Policy & Practice, Providence, RI, USA.
| | - Tao Liu
- Brown University School of Public Health, Data & Statistics Core of Brown Alcohol Research Center on HIV (ARCH), Providence, RI, USA.
| | - Roland C Merchant
- Harvard Medical School, Brigham and Women's Hospital Department of Emergency Medicine, Boston, MA, USA.
| |
Collapse
|
48
|
Dalal DS, Zhang T, Shireman TI. Medicare expenditures for conventional and biologic disease modifying agents commonly used for treatment of rheumatoid arthritis. Semin Arthritis Rheum 2020; 50:822-826. [PMID: 32896694 PMCID: PMC7453205 DOI: 10.1016/j.semarthrit.2020.08.002] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [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: 05/08/2020] [Revised: 07/17/2020] [Accepted: 08/04/2020] [Indexed: 12/15/2022]
Abstract
BACKGROUND Biologic disease modifying agents (bDMARDs) are an integral part of rheumatoid arthritis treatment guidelines but are associated with significant cost in the US. We present the trends in total spending and unit cost of conventional DMARDs (cDMARDs) as compared to bDMARDs in Medicare program. METHODS We used the Medicare drug spending data for the year 2012-2017 covering all part B (fee-for-service) and part D drugs. Total spending was calculated by summing spending across various drug formulations and unit drug cost by dividing total spending by number of doses dispensed. We present the 6-year trends in total spending, total beneficiary count and unit costs of each of the commonly used cDMARDs and bDMARDs. RESULTS Between 2012 and 2017, the total spending on the cDMARDs increased 5-folds from $98 million to $579 million; this was fraction of total spending on bDMARDs which increased from $4.3 to $10.0 billion. This increase was driven largely by unit costs of drug rather than number of beneficiaries. There was a 6-fold increase in the unit cost of generic hydroxychloroquine followed by methotrexate and leflunomide. Amongst bDMARDs, adalimumab and etanercept unit cost increased by 2-folds. The increase was less pronounced for office-administered products. CONCLUSIONS Despite the availability of several generic cDMARDs over decades, there were steep increases in the unit cost of these agents to "keep pace" with the increases in bDMARDs. As the number of elderly rheumatoid arthritis patients increases, policy interventions might be required to reduce the spending on both biologics and conventional DMARDs.
Collapse
Affiliation(s)
- Deepan S Dalal
- Division of Rheumatology, Department of Medicine, Brown University School of Medicine, Providence, RI, USA; Department of Health Services, Policy and Practices, Brown University School of Public Health, Providence, RI, USA.
| | - Tingting Zhang
- Department of Health Services, Policy and Practices, Brown University School of Public Health, Providence, RI, USA
| | - Theresa I Shireman
- Department of Health Services, Policy and Practices, Brown University School of Public Health, Providence, RI, USA
| |
Collapse
|
49
|
Shireman TI, Adia AC, Tan Y, Zhu L, Rhee J, Ogunwobi OO, Ma GX. Online versus in-person training of community health workers to enhance hepatitis B virus screening among Korean Americans: Evaluating cost & outcomes. Prev Med Rep 2020; 19:101131. [PMID: 32518742 PMCID: PMC7272502 DOI: 10.1016/j.pmedr.2020.101131] [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] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2019] [Revised: 05/12/2020] [Accepted: 05/23/2020] [Indexed: 01/10/2023] Open
Abstract
From 2014 to 2018, we developed and implemented culturally appropriate interventions delivered by community health workers (CHWs) in Pennsylvania and New Jersey. To determine the most cost-effective approach, we recruited 40 predominantly foreign-born Korean American CHWs and used cluster sampling to assign them into two training groups (online training vs. in-person training). We prospectively assessed the cost of training 40 Korean American CHWs and the cost of subsequent HBV educational workshops delivered by the CHWs. We also assessed these costs relative to the success of each training approach in recruiting participants for HBV screening and vaccination. We found that the training costs per participant were higher for in-person training ($1.71 versus $1.12), while workshop costs per participant were lower for in-person training ($2.19 versus $4.22). Workshop attendee costs were comparable. After accounting for site clustering, there were no significant differences in total costs per participant ($24.55 for the online-trained group and $26.05 for the in-person group). In-person trained CHWs were able to generate higher HBV screening and vaccination rates (49.3% versus 21.4% and 17.0% versus 5.9%, respectively) among their participants compared with online-trained CHWs. Given better outcomes and no differences in costs, in-person training dominated the online training option. Despite the potential for efficiency to be gained with online training, CHWs who attended live training outperformed their online-trained colleagues. Elements of the didactic approach or practice with peers in the live session may have contributed to the superior training effectiveness and, ultimately, improved cost-effectiveness of the in-person approach.
Collapse
Affiliation(s)
- Theresa I. Shireman
- Department of Health Services, Policy and Practice, School of Public Health, Brown University, Providence, RI, USA
| | - Alexander C. Adia
- Department of Health Services, Policy and Practice, School of Public Health, Brown University, Providence, RI, USA
| | - Yin Tan
- Center for Asian Health, Lewis Katz School of Medicine, Temple University, Philadelphia, PA, USA
| | - Lin Zhu
- Center for Asian Health, Lewis Katz School of Medicine, Temple University, Philadelphia, PA, USA
| | - Joanne Rhee
- Center for Asian Health, Lewis Katz School of Medicine, Temple University, Philadelphia, PA, USA
| | - Olorunseun O. Ogunwobi
- Department of Biological Sciences, Hunter College of the City University of New York, New York, NY, USA
| | - Grace X. Ma
- Center for Asian Health, Lewis Katz School of Medicine, Temple University, Philadelphia, PA, USA
- Department of Clinical Sciences, Lewis Katz School of Medicine, Temple University, Philadelphia, PA, USA
| |
Collapse
|
50
|
Lary CW, Hinton AC, Nevola KT, Shireman TI, Motyl KJ, Houseknecht KL, Lucas FL, Hallen S, Zullo AR, Berry SD, Kiel DP. Association of Beta Blocker Use With Bone Mineral Density in the Framingham Osteoporosis Study: A Cross-Sectional Study. JBMR Plus 2020; 4:e10388. [PMID: 32995691 PMCID: PMC7507481 DOI: 10.1002/jbm4.10388] [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] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2020] [Revised: 06/01/2020] [Accepted: 06/11/2020] [Indexed: 12/26/2022] Open
Abstract
Some, but not all, prior observational studies have shown that beta blocker (BB) use is associated with lower fracture risk and higher bone mineral density (BMD). Rodent studies show the mechanism to involve the reduction in the effects of beta‐adrenergic signaling on bone remodeling. Because previous studies did not have detailed information on dose, duration, and beta‐1 selectivity, we examined these in a cross‐sectional analysis of the association between BB use and hip and spine BMD using DXA with the Offspring Cohort of the Framingham Heart Study. The sample size was n = 1520, and 397 individuals used BBs. We used propensity score modeling to balance a comprehensive set of covariates using inverse probability of treatment weighting (IPTW) to minimize bias due to treatment indication. We found significant differences in BMD between BB users and non‐users for three of four BMD measurements (femoral neck: 3.1%, 95% CI, 1.1% to 5.0%; total femur: 2.9%, 95% CI, 0.9% to 4.9%; femoral trochanter: 2.4%, 95% CI, −0.1% to 5.0%; and lumbar spine: 2.7%, 95% CI, 0.2% to 5.0%). Results were found to be similar between sexes although the magnitude of association was larger for women. Similar differences were estimated for beta‐1 selective and nonselective BBs compared with no BB use. We modeled dose in categories (no BB use, low‐dose, high‐dose) and as a continuous variable and found an increasing dose response that levels off at higher doses. Finally, associations were similar for short‐term versus long‐term (≤4 years versus >4 years) use. In summary, this large comprehensive study shows that BB use is associated with higher BMD in a dose‐related manner regardless of beta‐1 specificity and duration of use, which supports the conduct of a randomized clinical trial of BBs for achieving improvements in BMD for individuals at risk of bone loss with aging. © 2020 The Authors. JBMR Plus published by Wiley Periodicals LLC. on behalf of American Society for Bone and Mineral Research.
Collapse
Affiliation(s)
- Christine W Lary
- Center for Outcomes Research and Evaluation Maine Medical Center Research Institute Portland ME USA
| | - Alexandra C Hinton
- Center for Outcomes Research and Evaluation Maine Medical Center Research Institute Portland ME USA
| | - Kathleen T Nevola
- Center for Outcomes Research and Evaluation Maine Medical Center Research Institute Portland ME USA.,Department of Cell, Molecular, and Developmental Biology, Graduate School of Biomedical Sciences Tufts University Boston MA USA
| | - Theresa I Shireman
- Center for Gerontology and Health Care Research Brown University School of Public Health Providence RI USA
| | - Katherine J Motyl
- Center for Molecular Medicine Maine Medical Center Research Institute Scarborough ME USA
| | - Karen L Houseknecht
- Department of Biomedical Sciences, College of Osteopathic Medicine University of New England Biddeford ME USA
| | - F Lee Lucas
- Center for Outcomes Research and Evaluation Maine Medical Center Research Institute Portland ME USA
| | - Sarah Hallen
- Center for Outcomes Research and Evaluation Maine Medical Center Research Institute Portland ME USA
| | - Andrew R Zullo
- Center for Gerontology and Health Care Research Brown University School of Public Health Providence RI USA.,Rhode Island Hospital Providence RI USA
| | - Sarah D Berry
- Department of Medicine Beth Israel Deaconess Medical CenterHarvard Medical School Boston MA USA.,Hinda and Arthur Marcus Institute for Aging ResearchHebrew SeniorLife Boston MA USA
| | - Douglas P Kiel
- Department of Medicine Beth Israel Deaconess Medical CenterHarvard Medical School Boston MA USA.,Hinda and Arthur Marcus Institute for Aging ResearchHebrew SeniorLife Boston MA USA
| |
Collapse
|