Audio-Only Telehealth Use Among Traditional Medicare Beneficiaries

This cross-sectional study analyzes how use of audio-only telehealth services by Medicare beneficiaries changed from 2020 to 2022 and assesses which patients would be most affected by policy reforms.

Clinicians Who Practice Primarily in Nursing Homes and the Quality of End-of-Life Care Among Residents

Importance

Clinician specialization in the care of nursing home (NH) residents or patients in skilled nursing facilities (SNFs) has become increasingly common. It is not known whether clinicians focused on NH care, often referred to as SNFists (ie, physicians, nurse practitioners, and physician assistants concentrating their practice in the NH or SNF setting), are associated with a reduced likelihood of burdensome transitions in the last 90 days of life for residents, which are a marker of poor-quality end-of-life (EOL) care.

Objective

To quantify the association between receipt of care from an SNFist and quality of EOL care for NH residents.

Design, Setting, and Participants

This cohort study analyzed Medicare fee-for-service claims for a nationally representative 20% sample of beneficiaries to examine burdensome transitions among NH decedents at the EOL from January 1, 2013, through December 31, 2019. Statistical analyses were conducted from December 2022 to June 2023.

Exposure

Receipt of care from an SNFist, defined as physicians and advanced practitioners who provided 80% or more of their evaluation and management visits in NHs annually.

Main Outcomes and Measures

This study used augmented inverse probability weighting in analyses of Medicare fee-for-service claims for a nationally representative 20% sample of beneficiaries. Main outcomes included 4 measures of burdensome transitions: (1) hospital transfer in the last 3 days of life; (2) lack of continuity in NHs after hospitalization in the last 90 days of life; (3) multiple hospitalizations in the last 90 days of life for any reason or any hospitalization for pneumonia, urinary tract infection, dehydration, or sepsis; and (4) any hospitalization in the last 90 days of life for an ambulatory care-sensitive condition.

Results

Of the 2 091 954 NH decedents studied (mean [SD] age, 85.4 [8.5] years; 1 470 724 women [70.3%]), 953 722 (45.6%) received care from SNFists and 1 138 232 (54.4%) received care from non-SNFists; 422 575 of all decedents (20.2%) experienced a burdensome transition at the EOL. Receipt of care by an SNFist was associated with a reduced risk of (1) hospital transfer in the last 3 days of life (-1.6% [95% CI, -2.5% to -0.8%]), (2) lack of continuity in NHs after hospitalization (-4.8% [95% CI, -6.7% to -3.0%]), and (3) decedents experiencing multiple hospitalizations for any reason or any hospitalization for pneumonia, urinary tract infection, dehydration, or sepsis (-5.8% [95% CI, -10.1% to -1.7%]). There was not a statistically significant association with the risk of hospitalization for an ambulatory care-sensitive condition in the last 90 days of life (0.0% [95% CI, -14.7% to 131.7%]).

Conclusions and Relevance

This study suggests that SNFists may be an important resource to improve the quality of EOL care for NH residents.

Use of Clinicians Who Focus on Nursing Home Care Among US Nursing Homes and Unplanned Rehospitalization

Importance

The number of physicians and advanced practitioners who focus their practice in nursing homes (NHs), often referred to as "SNFists" (ie, physicians, nurse practitioners, and physician assistants concentrating their practice in the nursing home or skilled nursing facility [SNF] setting) has increased dramatically. Little is known about the association of the NH medical care delivery models that use SNFists with the quality of postacute care.

Objective

To quantify the association between NH use of SNFists and facility-level, unplanned 30-day rehospitalization rates for patients receiving postacute care.

Design, Setting, and Participants

This cohort study used Medicare fee-for-service claims for all hospitalized beneficiaries discharged to 4482 NHs from January 1, 2012, through December 31, 2019. The study sample comprised NHs that did not have patients under the care of SNFists as of 2012. The treatment group included NHs that adopted at least 1 SNFist by the end of the study period. The control group included NHs that did not have patients under the care of a SNFist during the study period. SNFists were defined as generalist physicians and advanced practitioners with 80% or more of their Medicare Part B services delivered in NHs. Statistical analysis was conducted from January 2022 to April 2023.

Exposure

Nursing home adoption of 1 or more SNFists.

Main Outcomes and Measures

The main outcome was the NH 30-day unplanned rehospitalization rate. A facility-level analysis was conducted using an event study approach to estimate the association of an NH adopting 1 or more SNFists with its unplanned 30-day rehospitalization rate, adjusting for patient case mix, facility, and market characteristics. Changes in patient case mix were examined in secondary analyses.

Results

In this study of 4482 NHs, adoption of SNFists increased from 13.5% of facilities (550 of 4063) in 2013 to 52.9% (1935 of 3656) in 2018. Adjusted rehospitalization rates were not statistically different after SNFist adoption compared with before, with an estimated mean treatment effect of 0.05 percentage points (95% CI, -0.43 to 0.53 percentage points; P = .84). The share of Medicare-covered patients increased by 0.60 percentage points (95% CI, 0.21-0.99 percentage points; P = .003) in the year of SNFist adoption and by 0.54 percentage points (95% CI, 0.12-0.95 percentage points; P = .01) 1 year after adoption compared with NHs that did not adopt SNFists. The number of postacute admissions increased by 13.6 (95% CI, 9.7-17.5; P < .001) after SNFist adoption, but there was no statistically significant change in the acuity index.

Conclusions and Relevance

This cohort study suggests that NH adoption of SNFists was associated with an increase in the number of admissions for postacute care but was not associated with a change in rehospitalization rates. This may represent a strategy by NHs to maintain rehospitalization rates while increasing the volume of patients receiving postacute care, which typically results in higher profit margins.

The Association of Teamlets and Teams with Physician Burnout and Patient Outcomes

BACKGROUND

Primary care "teamlets" in which a staff member and physician consistently work together might provide a simple, cost-effective way to improve care, with or without insertion within a team.

OBJECTIVE

To determine the prevalence and performance of teamlets and teams.

DESIGN

Cross-sectional observational study linking survey responses to Medicare claims.

PARTICIPANTS

Six hundred eighty-eight general internists and family physicians.

INTERVENTIONS

Based on survey responses, physicians were assigned to one of four teamlet/team categories (e.g., teamlet/no team) and, in secondary analyses, to one of eight teamlet/team categories that classified teamlets into high, medium, and low collaboration as perceived by the physician (e.g., teamlet perceived-high collaboration/no team).

MAIN MEASURES

Descriptive: percentage of physicians in teamlet/team categories.

OUTCOME MEASURES

physician burnout; ambulatory care sensitive emergency department and hospital admissions; Medicare spending.

KEY RESULTS

77.4% of physicians practiced in teamlets; 36.7% in teams. Of the four categories, 49.1% practiced in the teamlet/no team category; 28.3% in the teamlet/team category; 8.4% in no teamlet/team; 14.1% in no teamlet/no team. 15.7%, 47.4%, and 14.4% of physicians practiced in perceived high-, medium-, and low-collaboration teamlets. Physicians who practiced neither in a teamlet nor in a team had significantly lower rates of burnout compared to the three teamlet/team categories. There were no consistent, significant differences in outcomes or Medicare spending by teamlet/team or teamlet perceived-collaboration/team categories compared to no teamlet/no team, for Medicare beneficiaries in general or for dual-eligible beneficiaries.

CONCLUSIONS

Most general internists and family physicians practice in teamlets, and some practice in teams, but neither practicing in a teamlet, in a team, or in the two together was associated with lower physician burnout, better outcomes for patients, or lower Medicare spending. Further study is indicated to investigate whether certain types of teamlet, teams, or teamlets within teams can achieve higher performance.

Perspectives of Physicians with Experience in Nursing Home Care on Telehealth Use During the COVID-19 Public Health Emergency

BACKGROUND

Despite expanded access to telehealth services for Medicare beneficiaries in nursing homes (NHs) during the COVID-19 public health emergency, information on physicians' perspectives on the feasibility and challenges of telehealth provision for NH residents is lacking.

OBJECTIVE

To examine physicians' perspectives on the appropriateness and challenges of providing telehealth in NHs.

PARTICIPANTS

Medical directors or attending physicians in NHs.

APPROACH

We conducted 35 semistructured interviews with members of the American Medical Directors Association from January 18 through January 29, 2021. Outcomes of the thematic analysis reflected perspectives of physicians experienced in NH care on telehealth use.

MAIN MEASURES

The extent to which participants used telehealth in NHs, the perceived value of telehealth for NH residents, and barriers to telehealth provision.

KEY RESULTS

Participants included 7 (20.0%) internists, 8 (22.9%) family physicians, and 18 (51.4%) geriatricians. Five common themes emerged: (1) direct care is needed to adequately care for residents in NHs; (2) telehealth may allow physicians to reach NH residents more flexibly during offsite hours and other scenarios when physicians cannot easily reach patients; (3) NH staff and other organizational resources are critical to the success of telehealth, but staff time is a major barrier to telehealth provision; (4) appropriateness of telehealth in NHs may be limited to certain resident populations and/or services; (5) conflicting views about whether telehealth use will be sustained over time in NHs. Subthemes included the role of resident-physician relationships in facilitating telehealth and the appropriateness of telehealth for residents with cognitive impairment.

CONCLUSIONS

Participants had mixed views on the effectiveness of telehealth in NHs. Staff resources to facilitate telehealth and the limitations of telehealth for NH residents were the most raised issues. These findings suggest that physicians in NHs may not view telehealth as a suitable substitute for most in-person services.

The Role Of Real Estate Investment Trusts In Staffing US Nursing Homes

In 2021 real estate investment trusts (REITs) held investments in 1,806 US nursing homes. REITs are for-profit public or private corporations that invest in income-producing properties. We created a novel database of REIT investments in US nursing homes, merged it with Medicare cost report data (2013-19), and used a difference-in-differences approach within an event study framework to compare staffing before and after a nursing home received REIT investment with staffing in for-profit nursing homes that did not receive REIT investment. REIT investment was associated with average relative staffing increases of 2.15 percent and 1.55 percent for licensed practical nurses (LPNs) and certified nursing assistants (CNAs), respectively. During the postinvestment period, registered nurse (RN) staffing was unchanged, but event study results showed a 6.25 percent decrease in years 2 and 3 after REIT investment. After the three largest REIT deals were excluded, REIT investments were associated with an overall 6.25 percent relative decrease in RN staffing and no changes in LPN and CNA staffing. Larger deals resulted in increases in LPN and CNA staffing, with no changes in RN staffing; smaller deals appeared to replace more expensive and skilled RN staffing with less expensive and skilled staff.

ADOPTION OF SNFISTS BY US NURSING HOMES DID NOT REDUCE REHOSPITALIZATION RATES AMONG POST–ACUTE CARE PATIENTS

SNFists, physicians and advanced practitioners who focus their practice in nursing homes, have grown in prevalence in recent years. In this retrospective cohort study, we measured the role of nursing home adoption of SNFists in rehospitalization rates. We used 100% Medicare facility and professional claims for hospitalized fee-for-service beneficiaries discharged to nursing homes in 2012-2019. We defined SNFists as generalist physicians and nurse practitioners with at least 80% of their Medicare Part B claims for nursing home care. All nursing homes that did not have a SNFist in 2012 were followed through 2019. We used an event study approach with staggered SNFist adoption to estimate the effect of a nursing home adopting at least one SNFist on the facility’s unplanned 30-day rehospitalization rate, adjusted for patient case mix, facility and market characteristics. Models included facility and year fixed effects. Standard errors were clustered at the facility level. Of the 6,616 nursing homes in the sample, 77% adopted SNFists by 2019. Nursing homes that adopted SNFists did not experience a statistically significant change in rehospitalization rate compared to those that did not adopt: rehospitalization rates decreased by 0.02 percentage points (95% CI -0.35 to 0.32; p=0.93) one year after SNFist adoption and by 0.15 percentage points (95% CI -1.01 to 0.70; p=0.73) six years after adoption, compared to the baseline difference between the groups in the year before adoption. In sum, despite the wide adoption of SNFists by US nursing homes, we did not observe an associated decrease in rehospitalization rates.

US Generalist Physicians and Groups That Focused Practice in a Single Care Setting: 2014-2017

BACKGROUND

Some generalist physicians whose training prepared them for primary care practice increasingly practice in a facility (eg, hospitals, nursing homes); however, whether this trend was accompanied by a complimentary rise in generalist physicians who focused their practice on office-based care is unknown.

OBJECTIVES

Our objective in this study was to examine trends in the prevalence of generalist physicians and physician groups that practice in a single setting.

RESEARCH DESIGN

This was a retrospective cross-sectional study of generalist physicians trained in family medicine, internal medicine, or geriatrics. We used 2014-2017 billing data for Medicare fee-for-service beneficiaries to measure the proportion of all patient visits made by physicians in the following care settings: office, outpatient hospital department, inpatient hospital, and other sites.

RESULTS

From 2014 to 2017, the proportion of generalist physicians who narrowed their practice to a single setting increased by 6.69% (from 62.80% to 67.00%, p for trend <0.001). In 2017, 4.63% of physician groups included more than 1 type of setting-based physicians.

CONCLUSIONS

Generalist physicians treating older adults increasingly narrowed their practice focus to a single type of health care setting. This trend was not accompanied by growth among physician groups that included different types of setting-based physicians. Further evaluation of the consequences of these trends on the fragmentation of primary care delivery across different health care settings and primary care outcomes is needed.

Association of Private Equity Investment in US Nursing Homes With the Quality and Cost of Care for Long-Stay Residents

Question

Is private equity acquisition of nursing homes associated with the quality or cost of care for long-stay nursing home residents?

Findings

In this cohort study with difference-in-differences analysis of 9864 US nursing homes, including 9632 residents in 302 nursing homes acquired by private equity firms and 249 771 residents in 9562 other for-profit nursing homes without private equity ownership, private equity acquisition of nursing homes was associated with higher costs and increases in emergency department visits and hospitalizations for ambulatory sensitive conditions.

Meaning

This study suggests that more stringent oversight and reporting on private equity ownership of nursing homes may be warranted.

Importance

Private equity firms have been acquiring US nursing homes; an estimated 5% of US nursing homes are owned by private equity firms.

Objective

To examine the association of private equity acquisition of nursing homes with the quality and cost of care for long-stay residents.

Design, Setting, and Participants

In this cohort study of 302 private equity nursing homes with 9632 residents and 9562 other for-profit homes with 249 771 residents, a novel national database of private equity nursing home acquisitions was merged with Medicare claims and Minimum Data Set assessments for the period from 2012 to 2018. Changes in outcomes for residents in private equity–acquired nursing homes were compared with changes for residents in other for-profit nursing homes. Analyses were performed from March 25 to June 23, 2021.

Exposure

Private equity acquisitions of 302 nursing homes between 2013 and 2017.

Main Outcomes and Measures

This study used difference-in-differences analysis to examine the association of private equity acquisition of nursing homes with outcomes. Primary outcomes were quarterly measures of emergency department visits and hospitalizations for ambulatory care–sensitive (ACS) conditions and total quarterly Medicare costs. Antipsychotic use, pressure ulcers, and severe pain were examined in secondary analyses.

Results

Of the 259 403 residents in the study (170 687 women [65.8%]; 211 154 White residents [81.4%]; 204 928 residents [79.0%] dually eligible for Medicare and Medicaid; mean [SD] age, 79.3 [5.6] years), 9632 residents were in 302 private equity–acquired nursing homes and 249 771 residents were in 9562 other for-profit homes. The mean quarterly rate of ACS emergency department visits was 14.1% (336 072 of 2 383 491), and the mean quarterly rate of ACS hospitalizations was 17.3% (412 344 of 2 383 491); mean (SD) total quarterly costs were $8050.00 ($9.90). Residents of private equity nursing homes experienced relative increases in ACS emergency department visits of 11.1% (1.7 of 15.3; 1.7 percentage points; 95% CI, 0.3-3.0 percentage points; P = .02) and in ACS hospitalizations of 8.7% (1.0 of 11.5; 1.0 percentage point; 95% CI, 0.2-1.1 percentage points; P = .003) compared with residents in other for-profit homes; quarterly costs increased 3.9% (270.37 of 6972.04; $270.37; 95% CI, $41.53-$499.20; P = .02) or $1081 annually per resident. Private equity acquisition was not significantly associated with antipsychotic use (−0.2 percentage points; 95% CI, −1.7 to 1.4 percentage points; P = .83), severe pain (0.2 percentage points; 95% CI, −1.1 to 1.4 percentage points; P = .79), or pressure ulcers (0.5 percentage points; 95% CI, −0.4 to 1.3 percentage points; P = .30).

Conclusions and Relevance

This cohort study with difference-in-differences analysis found that private equity acquisition of nursing homes was associated with increases in ACS emergency department visits and hospitalizations and higher Medicare costs.

Characterizing the direct care health workforce in the United States, 2010-2019

BACKGROUND

To describe the growth and characteristics of the direct care health workforce, encompassing home health aides, personal care aides, nursing assistants, and orderlies and psychiatric aides from 2010 to 2019 in the United States.

METHODS

Using nationally representative data from the 2010 to 2019 American Community Survey, we described the growth in the direct care health workforce overall and by type of direct care health worker. In addition, we examined the distribution of direct care workers by geographic region of the country, age categories, citizenship, world area of birth, income, health insurance status, and other characteristics.

RESULTS

From 2010 to 2019, the number of direct care health workers in the United States per 10,000 individuals decreased slightly from 135.81 in 2010 to 133.78 in 2019. Personal care aides made up 42.1% of the direct care health workforce in 2019, followed by nursing assistants (39.5%) and home health aides (16.3%). In 2019, the number of direct care health workers who were not U.S. citizens accounted for roughly 10% of all workers in each year. The relative percentage of direct care health workers that were not a citizen of the United States was highest among home health aides (16.3%). Among workers born outside of the United States, the majority were from Latin America, followed by Asia.

CONCLUSION

From 2010 to 2019, there was little growth in the direct care health workforce despite growing demand for direct care health workers. In the midst of the current and projected shortage of direct care health workers-particularly during the COVID-19 pandemic, longer-term solutions to improve retention of direct care health workers and increase the supply of direct care health workers may be needed.

P–370 RPL-protease A as a potential biomarker for predicting recurrent pregnancy loss

Study question

Could the reduction of RPL-protease A be involved in the dysfunctional trophoblast for resulting in recurrent pregnancy loss (RPL).

Summary answer

Low expression of RPL-protease A may result in RPL and low serum RPL-protease A level may be a potential biomarker for predicting RPL.

What is known already

The RPL-protease A is expressed and secreted by placenta. The RPL-protease A is involved in the pathogenesis of pre-eclampsia, and the serum RPL-protease A level is higher in the patients with pre-eclampsia than that of normal groups. In our previous study, we identified that the RPL-protease A mRNA level was lower in the villi of patients with RPL than that of normal groups.

Study design, size, duration

Using the CRISPR/Cas9 system, the RPL-protease A gene knockout BeWo cell (BeWo KO) line was established, and the wild type (BeWo WT) and BeWo KO cells were applied to investigate the roles of RPL-protease A in trophoblasts. The human serum RPL-protease A levels were investigated by Western blot analysis and ELISA kit.

Participants/materials, setting, methods

The cell-cell fusion, cell counting analysis, invasion and scratch wound assays, cell cycle analysis, and immunocytochemical analysis were used to investigate cellular functions of RPL-protease A in trophoblast. The sera were obtained from 32 normal pregnant women and 60 women with RPL. The Western blot analysis and ELISA were used for detection of serum RPL-protease A levels.

Main results and the role of chance

The β-hCG was detected in fused BeWo WT cells, while the BeWo KO cells cannot fuse and did not express the β-hCG. The ability of invasion was decreased, but the capacity of migration and proliferation was higher in BeWo KO cells than BeWo WT cells. Cell fusion related factor (β-hCG), and cell invasion related factors (MMP–2 and MMP–9) were highly expressed in BeWo WT cells, and cell related factor (FAK), and cell proliferation related factors (ERK, p38, JNK, MKK3, MKK6, Raf, and Ras) were highly expressed in BeWo KO cells. The Western blot analysis and ELISA indicate that the serum RPL-protease A level was decreased in patients with RPL compared to that of normal groups.

Limitations, reasons for caution

The results of this study have the limitation of RPL-protease A functions in vitro.

Wider implications of the findings: The cellular functions of RPL-protease A in trophoblasts were investigated to explain the pathogenesis of RPL, and low serum RPL-protease A level can be used for a potential biomarker predicting RPL.

Trial registration number

Not applicable

Medical Care Delivery in U.S. Nursing Homes: Current and Future Practice

The delivery of medical care services in U.S. nursing homes (NHs) is dependent on a workforce that comprises physicians, nurse practitioners, and physician assistants. Each of these disciplines operates under a unique regulatory framework while adhering to common standards of care. NH provider characteristics and their roles in NH care can illuminate potential links to clinical outcomes and overall quality of care with important policy and cost implications. This perspective provides an overview of what is currently known about medical provider practice in NH and organizational models of practice. Links to quality, both conceptual and established, are presented as is a research and policy agenda that addresses the gaps in the evidence base within the context of our ever-changing health care landscape.

Nursing Home Characteristics Associated With Resident COVID-19 Morbidity in Communities With High Infection Rates

This cross-sectional study uses data from the Centers for Medicare and Medicaid Services Nursing Home COVID-19 Public File to assess the characteristics associated with resident morbidity among 3008 nursing homes in US communities with the highest COVID-19 infection prevalence.

The patient-driven payment model: addressing perverse incentives, creating new ones

The Patient-Driven Payment Model addresses perverse incentives in Medicare's previous payment system for skilled nursing facilities, but it includes new incentives that may be problematic.

Characteristics of Nursing Homes by COVID-19 Cases Among Staff: March to August 2020

Objective

To measure the association between nursing home (NH) characteristics and Coronavirus Disease 2019 (COVID-19) prevalence among NH staff.

Design

Retrospective cross-sectional study.

Setting and Participants

Centers for Disease Control and Prevention COVID-19 database for US NHs between March and August 2020, linked to NH facility characteristics (LTCFocus database) and local COVID-19 prevalence (USA Facts).

Methods

We estimated the associations between NH characteristics, local infection rates, and other regional characteristics and COVID-19 cases among NH staff (nursing staff, clinical staff, aides, and other facility personnel) measured per 100 beds, controlling for the hospital referral regions in which NHs were located to account for local infection control practices and other unobserved characteristics.

Results

Of the 11,858 NHs in our sample, 78.6% reported at least 1 staff case of COVID-19. After accounting for local COVID-19 prevalence, NHs in the highest quartile of confirmed resident cases (413.5 to 920.0 cases per 1000 residents) reported 18.9 more staff cases per 100 beds compared with NHs that had no resident cases. Large NHs (150 or more beds) reported 2.6 fewer staff cases per 100 beds compared with small NHs (<50 beds) and for-profit NHs reported 0.8 fewer staff cases per 100 beds compared with nonprofit NHs. Higher occupancy and more direct-care hours per day were associated with more staff cases (0.4 more cases per 100 beds for a 10% increase in occupancy, and 0.7 more cases per 100 beds for an increase in direct-care staffing of 1 hour per resident day, respectively). Estimates associated with resident demographics, payer mix, or regional socioeconomic characteristics were not statistically significant.

Conclusions and Implications

These findings highlight the urgent need to support facilities with emergency resources such as back-up staff and protocols to reduce resident density within the facility, which may help stem outbreaks.

End user information needs for a SMART on FHIR-based automated transfer form to support the care of nursing home patients during emergency department visits

Nursing home (NH) patients are extensive users of emergency department (ED) services. Problematically, poor information sharing and incomplete access to information complicates the delivery of care in EDs for NH patients. Paper-based transfer forms can support information sharing, but have significant limitations. Standards-based automated transfer-forms that leverage health information exchange data may address the limitations of paper-based forms and better support care delivery. This study developed a prototype SMART on FHIR automated transfer form for NH patients using priority data elements identified through individual interviews, a review of existing transfer forms, a targeted survey of end users, and a design workshop. Analyses were grounded in the 5 Rights of clinical decision support framework. The most valuable data elements included: emergency contact/healthcare proxy, current medication list, reason for transfer to the ED, baseline neurological state, and relevant diagnoses / medical history. The working prototype was successfully deployed within an Amazon Web Service environment.

Organizational characteristics and perceptions of clinical event notification services in healthcare settings: a study of health information exchange

OBJECTIVE

Event notification systems are an approach to health information exchange (HIE) that notifies end-users of patient interactions with the healthcare system through real-time automated alerts. We examined associations between organizational capabilities and perceptions of event notification system use.

MATERIALS AND METHODS

We surveyed representatives (n = 196) from healthcare organizations (n = 96) that subscribed to 1 of 3 Health Information Organizations' event notification services in New York City (response rate = 27%). The survey was conducted in Fall 2017 and Winter 2018. Surveys measured respondent characteristics, perceived organizational capabilities, event notification use, care coordination, and care quality. Exploratory factor analysis was used to identify relevant independent and dependent variables. We examined the relationship between organizational capabilities, care coordination, and care quality using multilevel linear regression models with random effects.

RESULTS

Respondents indicated that the majority of their organizations provided follow-up care for emergency department visits (66%) and hospital admissions (73%). Perceptions of care coordination were an estimated 57.5% (β = 0.575; P < 0.001) higher among respondents who reported event notifications fit within their organization's existing workflows. Perceptions of care quality were 46.5% (β = 0.465; P < 0.001) higher among respondents who indicated event notifications fit within existing workflows and 23.8% (β = 0.238; P < 0.01) higher where respondents reported having supportive policies and procedures for timely response and coordination of event notifications.

DISCUSSION AND CONCLUSION

Healthcare organizations with specific workflow processes and positive perceptions of fit are more likely to use event notification services to improve care coordination and care quality. In addition, event notification capacity and patient consent procedures influence how end-users perceive event notification services.

Comparative Performance of Private Equity-Owned US Nursing Homes During the COVID-19 Pandemic

IMPORTANCE

It is not known whether nursing homes with private equity (PE) ownership have performed better or worse than other nursing homes during the coronavirus disease 2019 (COVID-19) pandemic.

OBJECTIVE

To evaluate the comparative performance of PE-owned nursing homes on COVID-19 outcomes.

DESIGN, SETTING, AND PARTICIPANTS

This cross-sectional study of 11 470 US nursing homes used the Nursing Home COVID-19 Public File from May 17, 2020, to July 2, 2020, to compare outcomes of PE-owned nursing homes with for-profit, nonprofit, and government-owned homes, adjusting for facility characteristics.

EXPOSURE

Nursing home ownership status.

MAIN OUTCOMES AND MEASURES

Self-reported number of COVID-19 cases and deaths and deaths by any cause per 1000 residents; possessing 1-week supplies of personal protective equipment (PPE); staffing shortages.

RESULTS

Of 11 470 nursing homes, 7793 (67.9%) were for-profit; 2523 (22.0%), nonprofit; 511 (5.3%), government-owned; and 543 (4.7%), PE-owned; with mean (SD) COVID-19 cases per 1000 residents of 88.3 [2.1], 67.0 [3.8], 39.8 [7.6] and 110.8 [8.1], respectively. Mean (SD) COVID-19 deaths per 1000 residents were 61.9 [1.6], 66.4 [3.0], 56.2 [7.3], and 78.9 [5.9], respectively; mean deaths by any cause per 1000 residents were 78.1 [1.3], 91.5 [2.2], 67.6 [4.5], and 87.9 [4.8], respectively. In adjusted analyses, government-owned homes had 35.5 (95% CI, -69.2 to -1.8; P = .03) fewer COVID-19 cases per 1000 residents than PE-owned nursing homes. Cases in PE-owned nursing homes were not statistically different compared with for-profit and nonprofit facilities; nor were there statistically significant differences in COVID-19 deaths or deaths by any cause between PE-owned nursing homes and for-profit, nonprofit, and government-owned facilities. For-profit, nonprofit, and government-owned nursing homes were 10.5% (9.1 percentage points; 95% CI, 1.8 to 16.3 percentage points; P = .006), 15.0% (13.0 percentage points; 95% CI, 5.5 to 20.6 percentage points; P < .001), and 17.0% (14.8 percentage points; 95% CI, 6.5 to 23.0 percentage points; P < .001), respectively, more likely to have at least a 1-week supply of N95 masks than PE-owned nursing homes. They were 24.3% (21.3 percentage points; 95% CI, 11.8 to 30.8 percentage points; P < .001), 30.7% (27.0 percentage points; 95% CI, 17.7 to 36.2 percentage points; P < .001), and 29.2% (25.7 percentage points; 95% CI, 16.1 to 35.3 percentage points; P < .001) more likely to have a 1-week supply of medical gowns than PE-owned nursing homes. Government nursing homes were more likely to have a shortage of nurses (6.9 percentage points; 95% CI, 0.0 to 13.9 percentage points; P = .049) than PE-owned nursing homes.

CONCLUSIONS AND RELEVANCE

In this cross-sectional study, PE-owned nursing homes performed comparably on staffing levels, resident cases, and deaths with nursing homes with other types of ownership, although their shortages of PPE may warrant monitoring.

Long-Term Care, Residential Facilities, and COVID-19: An Overview of Federal and State Policy Responses

The COVID-19 pandemic has disproportionately affected residents and staff at long-term care (LTC) and other residential facilities in the United States. The high morbidity and mortality at these facilities has been attributed to a combination of a particularly vulnerable population and a lack of resources to mitigate the risk. During the first wave of the pandemic, the federal and state governments received urgent calls for help from LTC and residential care facilities; between March and early June of 2020, policymakers responded with dozens of regulatory and policy changes. In this article, we provide an overview of these responses by first summarizing federal regulatory changes and then reviewing state-level executive orders. The policy and regulatory changes implemented at the federal and state levels can be categorized into the following 4 classes: (1) preventing virus transmission, which includes policies relating to visitation restrictions, personal protective equipment guidance, and testing requirements; (2) expanding facilities' capacities, which includes both the expansion of physical space for isolation purposes and the expansion of workforce to combat COVID-19; (3) relaxing administrative requirements, which includes measures enacted to shift the attention of caretakers and administrators from administrative requirements to residents' care; and (4) reporting COVID-19 data, which includes the reporting of cases and deaths to residents, families, and administrative bodies (such as state health departments). These policies represent a snapshot of the initial efforts to mitigate damage inflicted by the pandemic. Looking ahead, empirical evaluation of the consequences of these policies-including potential unintended effects-is urgently needed. The recent availability of publicly reported COVID-19 LTC data can be used to inform the development of evidence-based regulations, though there are concerns of reporting inaccuracies. Importantly, these data should also be used to systematically identify hot spots and help direct resources to struggling facilities.

Usage of query-based health information exchange after event notifications

Objectives

This study sought to quantify the association between event notifications and subsequent query-based health information exchange (HIE) use among end users of three different community health information organizations.

Materials and Methods

Using system-log data merged with user characteristics, regression-adjusted estimates were used to describe the association between event notifications and subsequent query-based HIE usage.

Results

Approximately 5% of event notifications were associated with query-based HIE usage within 30 days. In adjusted models, odds of query-based HIE usage following an event notification were higher for older patients and for alerts triggered by a discharge event. Query-based HIE usage was more common among specialty clinics and Federally Qualified Health Centers than primary care organizations.

Discussion and Conclusion

In this novel combination of data, 1 in 20 event notifications resulted in subsequent query-based HIE usage. Results from this study suggest that event notifications and query-based HIE can be applied together to address clinical and population health use cases.

Do Children with Special Health Care Needs with Anxiety have Unmet Health Care Needs? An Analysis of a National Survey

OBJECTIVE

To describe differences in health care needs between Children with Special Health Care Needs (CSHCN) with and without anxiety and examine the association between anxiety and unmet health care needs.

METHODS

We analyzed data from the 2009/2010 national survey of CSHCN. The independent variable was anxiety. The main outcomes were health care needs and unmet needs. Covariates included demographics, other co-morbid conditions, and the presence and quality of a medical home. We used bivariate analyses and multivariable logistic regression to assess the relationships among anxiety, covariates, and the outcomes. We stratified our analysis by age (6-11 years, 12-17 years). Propensity score matched paired analysis was used as a sensitivity analysis.

RESULTS

Our final sample included 14,713 6-11 year-olds and 15,842 12-17-year-olds. Anxiety was present in 16% of 6-11 year-olds and 23% or 12-17 year-olds. In bivariate analyses, CSHCN with anxiety had increased health care needs and unmet needs, compared to CSHCN without anxiety. In multivariable analyses, only children 12-17 years old with anxiety had increased odds of having an unmet health care need compared to those children without anxiety (OR 1.44 [95% CI 1.17-1.78]). This was confirmed in the propensity score matching analysis (OR 1.12, [95% CI 1.02-1.22]). The specific unmet needs for older CSHCN with anxiety were mental health care (OR 1.54 [95% CI 1.09-2.17]) and well child checkups (OR 2.01 [95% CI 1.18-3.44]).

CONCLUSION

Better integration of the care for mental and physical health is needed to ensure CSHCN with anxiety have all of their health care needs met.

Association Between Clinician Specialization in Nursing Home Care and Nursing Home Clinical Quality Scores

IMPORTANCE

While the number of prescribing clinicians (physicians and nurse practitioners) who provide any nursing home care remained stable over the past decade, the number of clinicians who focus their practice exclusively on nursing home care has increased by over 30%.

OBJECTIVES

To measure the association between regional trends in clinician specialization in nursing home care and nursing home quality.

DESIGN

Retrospective cross-sectional study.

SETTING AND PARTICIPANTS

Patients treated in 15,636 nursing homes in 305 US hospital referral regions between 2013 and 2016.

MEASURES

Clinician specialization in nursing home care for 2012-2015 was measured using Medicare fee-for-service billings. Nursing home specialists were defined as generalist physicians (internal medicine, family medicine, geriatrics, and general practice) or advanced practitioners (nurse practitioners and physician assistants) with at least 90% of their billings for care in nursing homes. The number of clinicians was aggregated at the hospital referral region level and divided by the number of occupied Medicare-certified nursing home beds. Nursing Home Compare quality measure scores for 2013-2016 were aggregated at the HHR level, weighted by occupied beds in each nursing home in the hospital referral region. We measured the association between the number of nursing home specialists per 1000 beds and the clinical quality measure scores in the subsequent year using linear regression.

RESULTS

An increase in nursing home specialists per 1000 occupied beds in a region was associated with lower use of long-stay antipsychotic medications and indwelling bladder catheters, higher prevalence of depressive symptoms, and was not associated with urinary tract infections, use of restraints, or short-stay antipsychotic use.

CONCLUSIONS AND IMPLICATIONS

Higher prevalence of nursing home specialists was associated with regional improvements in 2 of 6 quality measures. Future studies should evaluate whether concentrating patient care among clinicians who specialize in nursing home practice improves outcomes for individual patients. The current findings suggest that prescribing clinicians play an important role in nursing home care quality.

Adoption of Health Information Technology Among US Nursing Facilities

OBJECTIVES

Nursing facilities have lagged behind in the adoption of interoperable health information technology (ie technologies that allow the sharing and use of electronic patient information between different information systems). The objective of this study was to estimate the nationwide prevalence of electronic health record (EHR) adoption among nursing facilities and to identify the factors associated with adoption.

DESIGN

Cross-sectional survey.

SETTING & PARTICIPANTS

We surveyed members of the Society for Post-Acute & Long-Term Care Medicine (AMDA) about their organizations' health information technology usage and characteristics.

MEASUREMENTS

Using questions adopted from existing instruments, the survey measured nursing home's EHR adoption, the ability to send, receive, search and integrate electronic information, as well as barriers to usage. Additionally, we linked survey responses to public use secondary data sources to construct measurements for 8 determinants known to be associated with organizational adoption: innovativeness, functional differentiation, role specialization, administrative intensity, professionalism, complexity, technical knowledge resources, and slack resources. A series of regression models estimated the association between potential determinants and technology adoption.

RESULTS

84% of nursing facilities reported using an EHR. After controlling for all other factors, respondents who characterized their organization as more innovative had more than 6 times the odds (adjusted odds ratio = 6.39, 95% confidence interval = 2.69, 15.21) of adopting an EHR. Organization innovativeness was also associated with an increased odds of being able to send, integrate, and search for electronic information. The most commonly identified barrier to sharing clinical information among nursing facilities with an EHR was a reported absence of interoperability (57%).

CONCLUSIONS/IMPLICATIONS

An organizational culture that fosters innovation and awareness campaigns by professional societies may facilitate further adoption and effective use of technology. This will be increasingly important as policy makers continue to emphasize the use of EHRs and interoperability to improve the quality of care in nursing facilities.

Landscape of Elderly Suicide in South Korea: Its Trend According to Age, Gender, and Educational Attainment

South Korea has one of the highest suicide rates in the world, and the most alarming suicide rate is among its elders. This study aims to understand the social, historical, and cultural context of the Korean older adults and examine suicide trends based on that understanding. The results show that the suicide risk increases with age, the male suicide rate outweighs that of females, and the suicide rate decreases with educational attainment. In addition, several suggestions for reducing elderly suicide rate are addressed, including differentiating the existing social services for elders by age and expanding suicide prevention programs beyond schools to communities so that all people in need can access them.

Medicare Advantage enrollees' use of nursing homes: trends and nursing home characteristics

OBJECTIVES

To examine temporal trends in the prevalence of nursing home (NH) patients participating in Medicare Advantage (MA) and to identify the characteristics of both these patients and the NHs that provide care for them.

STUDY DESIGN

Retrospective cohort study.

METHODS

Data sources included the Medicare enrollment file, Minimum Data Set, and facility-level data from the Certification and Survey Provider Enhanced Reporting system. Longitudinal trends of NH use by MA enrollees were examined over the period 2000 to 2013 and logistic regression models were used to identify facility characteristics associated with having a high proportion of MA patients.

RESULTS

The proportion of MA enrollees in NHs more than doubled between 2000 and 2013, increasing 125% during this period. Notable differences in facility characteristics were found between NHs that serve high proportions of MA enrollees and other NHs. High-MA NHs tended to be larger facilities affiliated with chains. These NHs also had better quality indicators, such as higher staffing levels, lower use of antipsychotics, and lower odds of rehospitalization. Additionally, high-MA NHs were more likely to be in counties with higher Medicare managed care penetration and less market concentration.

CONCLUSIONS

MA plans may be selectively contracting with NHs, as evidenced by the larger shares of MA patients who have been placed in facilities with better performance on quality measures. This may reflect MA plans concentrating enrollees in specific facilities and building "networks" of postacute and long-term care providers that provide better and more efficient care.

Fuzzy set-based generalized multifactor dimensionality reduction analysis of gene-gene interactions

BACKGROUND

Gene-gene interactions (GGIs) are a known cause of missing heritability. Multifactor dimensionality reduction (MDR) is one of most commonly used methods for GGI detection. The generalized multifactor dimensionality reduction (GMDR) method is an extension of MDR method that is applicable to various types of traits, and allows covariate adjustments. Our previous Fuzzy MDR (FMDR) is another extension for overcoming simple binary classification. FMDR uses continuous member-ship values instead of binary membership values 0 and 1, improving power for detecting causal SNPs and more intuitive interpretations in real data analysis. Here, we propose the fuzzy generalized multifactor dimensionality reduction (FGMDR) method, as a combined analysis of fuzzy set-based analysis and GMDR method, to detect GGIs associated with diseases using fuzzy set theory.

RESULTS

Through simulation studies for different types of traits, the proposed FGMDR showed a higher detection ratio of causal SNPs, compared to GMDR. We then applied FGMDR to two real data: Crohn's disease (CD) data from the Wellcome Trust Case Control Consortium (WTCCC) with a binary phenotype and the Homeostasis Model Assessment of Insulin Resistance (HOMA-IR) data from Korean population with a continuous phenotype. The interactions derived by our method include the pre-reported interactions associated with phenotypes.

CONCLUSIONS

The proposed FGMDR performs well for GGI detection with covariate adjustments. The program written in R for FGMDR is available at http://statgen.snu.ac.kr/software/FGMDR .

Hospitalization event notifications and reductions in readmissions of Medicare fee-for-service beneficiaries in the Bronx, New York

Objective

Follow-up with a primary care provider after hospital discharge has been associated with a reduced likelihood of readmission. However, primary care providers are frequently unaware of their patients' hospitalizations. Event notification may be an effective tool for reducing readmissions by notifying primary care providers when their patients have been admitted to and discharged from a hospital.

Materials and Methods

We examined the effect of an event notification system on 30-day readmissions in the Bronx, New York. The Bronx has among the highest readmission rates in the country and is a particularly challenging setting to improve care due to the low socioeconomic status of the county and high rates of poor health behaviors among its residents. The study cohort included 2559 Medicare fee-for-service beneficiaries associated with 14 141 hospital admissions over the period January 2010 through June 2014. Linear regression models with beneficiary-level fixed-effects were used to estimate the impact of event notifications on readmissions by comparing the likelihood of rehospitalization for a beneficiary before and after event notifications were active.

Results

The unadjusted 30-day readmission rate when event notifications were not active was 29.5% compared to 26.5% when alerts were active. Regression estimates indicated that active hospitalization alert services were associated with a 2.9 percentage point reduction in the likelihood of readmission (95% confidence interval: -5.5, -0.4).

Conclusions

Alerting providers through event notifications may be an effective tool for improving the quality and efficiency of care among high-risk populations.

Preferred Provider Relationships Between Medicare Advantage Plans and Skilled Nursing Facilities Reduce Switching Out of Plans: An Observational Analysis

Unlike traditional Medicare, Medicare Advantage (MA) plans contract with specific skilled nursing facilities (SNFs). Patients treated in an MA plan's preferred SNF may benefit from enhanced coordination and have a lower likelihood of switching out of their plan. Using 2011-2014 Medicare enrollment data, the Medicare Healthcare Effectiveness Data and Information Set, and the Minimum Data Set, we examined Medicare enrollees who were newly admitted to SNFs in 2012-2013. We used the Centers for Medicare & Medicaid Services star rating to distinguish between MA plans and show how SNF concentration experienced by patients varies between patients in plans with different star ratings. We found that highly rated MA plans steer their patients to a smaller number of SNFs, and these patients are less likely to switch out of their plans. Strengthening the MA plan-SNF relationship may lower disenrollment rates for SNF beneficiaries, imparting benefits to both patients and payers.

Survival Benefit of Early Cancer Detection Through Regular Endoscopic Screening for De Novo Gastric and Colorectal Cancers in Korean Liver Transplant Recipients

BACKGROUND

De novo malignancy is not uncommon after liver transplantation (LT). Gastric cancer is one of the most common malignancies in both the Korean general population and LT recipients, and colorectal cancer prevalence is gradually increasing.

METHODS

Among 3690 adult recipients who underwent LT from January 1999 and December 2013, the screening patterns and prognosis of 26 cases of gastric cancer and 22 cases of colorectal cancer were analyzed.

RESULTS

For gastric cancer, the mean patient age was 54.6 ± 6.2 years at LT and 59.5 ± 6.7 years at cancer diagnosis, with a post-transplant interval of 60.2 ± 29.8 months. Patients were divided into regular (n = 18) and non-regular (n = 8) screening groups, with early cancer found in 14 and 0 patients; their 2-year survival rates after cancer diagnosis were 93.1% and 33.3% (P = .006), respectively. Endoscopic resection was successfully performed in 8 patients, all in the regular screening group. For colorectal cancer, the mean patient age was 53.3 ± 6.1 years at LT and 58.1 ± 6.7 years at cancer diagnosis, with a post-transplant interval of 54.3 ± 38.0 months. Patients were divided into regular (n = 19) and non-regular (n = 3) screening groups, with early cancer found in 12 and 0 patients; their 2-year survival rates after cancer diagnosis of 92.3% and 33.3% (P = .003), respectively. Endoscopic resection was successfully performed in 6 patients, all in the regular screening group.

CONCLUSIONS

LT recipients are strongly advised to undergo regular screening studies for various de novo malignancies, especially cancers common in the general population. Regular endoscopic screening contributes to the timely detection of gastric and colorectal cancers, improving post-treatment survival outcomes.

Use of Health Information Exchange and Repeat Imaging Costs

PURPOSE

The aim of this study was to quantify the association between health information exchange (HIE) use and cost savings attributable to repeat imaging.

METHODS

Imaging procedures associated with HIE were compared with concurrent controls on the basis of propensity score matching over the period from 2009 to 2010 in a longitudinal cohort study. The study sample (n = 12,620) included patients ages 18 years and older enrolled in the two largest commercial health plans in a 13-county region of western New York State served by the Rochester Regional Health Information Organization. The primary outcome was a continuous measure of costs associated with repeat imaging. The determinant of interest, HIE use, was defined as system access after the initial imaging procedure and before repeat imaging.

RESULTS

HIE use was associated with an overall estimated annual savings of $32,460 in avoided repeat imaging, or $2.57 per patient. Basic imaging (radiography, ultrasound, and mammography) accounted for 85% of the estimated avoided cases of repeat imaging. Advanced imaging (CT and MRI) accounted for 13% of avoided procedures but constituted half of the estimated savings (50%).

CONCLUSIONS

HIE systems may reduce costs associated with repeat imaging. Although inexpensive imaging procedures constituted the largest proportion of avoided repeat imaging in our study, most of the estimated cost savings were due to small reductions in repeated advanced imaging procedures. HIE systems will need to be leveraged in ways that facilitate greater reductions in advanced imaging to achieve appreciable cost savings.

Favorable Risk Selection in Medicare Advantage: Trends in Mortality and Plan Exits Among Nursing Home Beneficiaries

The 2003 Medicare Modernization Act (MMA) increased payments to Medicare Advantage plans and instituted a new risk-adjustment payment model to reduce plans' incentives to enroll healthier Medicare beneficiaries and avoid those with higher costs. Whether the MMA reduced risk selection remains debatable. This study uses mortality differences, nursing home utilization, and switch rates to assess whether the MMA successfully decreased risk selection from 2000 to 2012. We found no decrease in the mortality difference or adjusted difference in nursing home use between plan beneficiaries pre- and post the MMA. Among beneficiaries with nursing home use, disenrollment from Medicare Advantage plans declined from 20% to 12%, but it remained 6 times higher than the switch rate from traditional Medicare to Medicare Advantage. These findings suggest that the MMA was not associated with reductions in favorable risk selection, as measured by mortality, nursing home use, and switch rates.

Unpacking Collaborative Care for Depression: Examining Two Essential Tasks for Implementation

OBJECTIVE

This study examined how two key process-of-care tasks of the collaborative care model (CCM) predict patient depression outcomes.

METHODS

Registry data were from a large implementation of the CCM in Washington State and included 5,439 patient-episodes for patients age 18 or older with a baseline Patient Health Questionnaire-9 (PHQ-9) score of ≥10 and at least one follow-up contact with the CCM care manager within 24 weeks of initial contact. Key CCM tasks examined were at least one care manager follow-up contact within four weeks of initial contact and at least one psychiatric consultation between weeks 8 and 12 for patients not responding to treatment by week 8. Clinically significant improvement in depression symptoms was defined as achieving a PHQ-9 score of <10 or a 50% or more reduction in PHQ-9 score compared with baseline. Bivariate and multivariate (logistic and proportional hazard models) analyses were conducted to examine how fidelity with either task predicted outcomes. All analyses were conducted with the original sample and with a propensity score-matched sample.

RESULTS

Four-week follow-up was associated with a greater likelihood of achieving improvement in depression (odds ratio [OR]=1.63, 95% confidence interval [CI]=1.23-2.17) and a shorter time to improvement (hazard ratio=2.06, CI=1.67-2.54). Psychiatric consultation was also associated with a greater likelihood of improvement (OR=1.44, CI=1.13-1.84) but not with a shorter time to improvement. Propensity score-matched analysis yielded very similar results.

CONCLUSIONS

Findings support efforts to improve fidelity to the two process-of-care tasks and to include these tasks among quality measures for CCM implementation.

Abstract P5-04-20: TLE1 protein expression in HER2-positive and triple-negative breast cancer

Purpose

Transducin-like enhancer protein 1 (TLE1) is a member of the Groucho (Gro)/TLE family of transcriptional co-repressors that regulate the transcriptional activity of a wide range of genes. TLE1 has been shown to be a specific and diagnostically useful immunohistochemical marker for synovial sarcoma. However, there have been few reports of the status of TLE1 in breast cancers. The purpose of this study was to clarify the nuclear expression of TLE1 in 511 Korean breast cancers by immunohistochemistry (IHC) and to correlate the findings to clinicopathologic variables including prognostic significance.

Methods

IHC was performed on tissue microarrays (TMAs) in 511 cases of breast cancer. Associations between the TLE1 expression and the clinicopathologic characteristics were retrospectively analyzed. Progression-free survival and disease-specific survival was assessed by the Kaplan–Meier method and Cox regression model.

Results

Of 511 cases of breast cancer, high expression of the TLE1 was detected in 63 (12.3%) cases. TLE1-high expression was strongly associated with HER2-positive breast cancer phenotype (p &lt; 0.001) and triple-negative breast cancer phenotype (p &lt; 0.001). Furthermore, high TLE1was significantly associated with high histologic grade (p &lt; 0.001), node-negative (p =0.011), estrogen receptor negativity (p &lt; 0.001), progesterone receptor negativity (p &lt; 0.001), CK5/6 positivity (p &lt; 0.001), epidermal growth factor receptor positivity (p &lt; 0.001), high ki-67 proliferative index (p &lt; 0.001) and high p53 expression (p &lt; 0.001). Survival analysis demonstrated no significant association between TLE1 expression and disease progression and cancer-related death (p =0.112 and p =0.068, respectively).

Conclusion

Our results show that high TLE1expression is significantly associated with HER2-positive and triple-negative breast cancer. TLE1 may represent a potential therapeutic target for this aggressive disease, which warrants further investigation.

Citation Format: Lee HJ, Oh M-H, Lee J-H, Cho HD, Jang S-H, Jung HY, Kim K-J. TLE1 protein expression in HER2-positive and triple-negative breast cancer. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr P5-04-20.

Image Sharing Technologies and Reduction of Imaging Utilization: A Systematic Review and Meta-analysis

INTRODUCTION

Image sharing technologies may reduce unneeded imaging by improving provider access to imaging information. A systematic review and meta-analysis were conducted to summarize the impact of image sharing technologies on patient imaging utilization.

METHODS

Quantitative evaluations of the effects of PACS, regional image exchange networks, interoperable electronic heath records, tools for importing physical media, and health information exchange systems on utilization were identified through a systematic review of the published and gray English-language literature (2004-2014). Outcomes, standard effect sizes (ESs), settings, technology, populations, and risk of bias were abstracted from each study. The impact of image sharing technologies was summarized with random-effects meta-analysis and meta-regression models.

RESULTS

A total of 17 articles were included in the review, with a total of 42 different studies. Image sharing technology was associated with a significant decrease in repeat imaging (pooled effect size [ES] = -0.17; 95% confidence interval [CI] = [-0.25, -0.09]; P < .001). However, image sharing technology was associated with a significant increase in any imaging utilization (pooled ES = 0.20; 95% CI = [0.07, 0.32]; P = .002). For all outcomes combined, image sharing technology was not associated with utilization. Most studies were at risk for bias.

CONCLUSIONS

Image sharing technology was associated with reductions in repeat and unnecessary imaging, in both the overall literature and the most-rigorous studies. Stronger evidence is needed to further explore the role of specific technologies and their potential impact on various modalities, patient populations, and settings.