Publications by authors named "Bita A Kash"

66 Publications

Factors Affecting Adoption of a Technology-Based Tool for Diabetes Self-Management Education and Support Among Adult Patients with Type 2 Diabetes in South Texas.

Sci Diabetes Self Manag Care 2021 Jun 17;47(3):189-198. Epub 2021 Apr 17.

Center for Outcomes Research, Houston Methodist, Houston, Texas.

Purpose: The purpose of this study is to describe a novel computerized diabetes education tool and explore factors influencing self-selection and use among primarily Hispanic patients diagnosed with type 2 diabetes in south Texas.

Methods: Study participants included 953 adult patients with type 2 diabetes enrolled in a diabetes education program between July 1, 2016, and June 30, 2017. Participants were asked to choose either a new technology-based diabetes education tool with a touch-screen device or a traditional face-to-face education method. Multivariate logistic regression analysis was applied to identify factors associated with adopting the computerized diabetes education tool among the patients.

Results: When comparing technology-based tool adopters and nonadopters, several demographic and health-related factors differentiated technology use in bivariate analyses. The multivariate logistic regression model showed that Hispanic patients were less likely to choose a technology-based tool. Patients who perceived their health status as excellent/good were more likely to adopt the technologic education method than those with fair/poor perceived health status. A1C level was negatively associated with self-selection of technology.

Conclusions: Specific demographic and health-related characteristics are significant contributing factors to patients' adoption of a technology-based diabetes education tool. Health care providers can utilize these findings to target and refer specific patients to a computerized diabetes education tool for more effective diabetes care and to optimize technology adoption success.
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http://dx.doi.org/10.1177/26350106211004885DOI Listing
June 2021

Rapid Response to Drive COVID-19 Research in a Learning Health Care System: Rationale and Design of the Houston Methodist COVID-19 Surveillance and Outcomes Registry (CURATOR).

JMIR Med Inform 2021 Feb 23;9(2):e26773. Epub 2021 Feb 23.

Houston Methodist, Houston, TX, United States.

Background: The COVID-19 pandemic has exacerbated the challenges of meaningful health care digitization. The need for rapid yet validated decision-making requires robust data infrastructure. Organizations with a focus on learning health care (LHC) systems tend to adapt better to rapidly evolving data needs. Few studies have demonstrated a successful implementation of data digitization principles in an LHC context across health care systems during the COVID-19 pandemic.

Objective: We share our experience and provide a framework for assembling and organizing multidisciplinary resources, structuring and regulating research needs, and developing a single source of truth (SSoT) for COVID-19 research by applying fundamental principles of health care digitization, in the context of LHC systems across a complex health care organization.

Methods: Houston Methodist (HM) comprises eight tertiary care hospitals and an expansive primary care network across Greater Houston, Texas. During the early phase of the pandemic, institutional leadership envisioned the need to streamline COVID-19 research and established the retrospective research task force (RRTF). We describe an account of the structure, functioning, and productivity of the RRTF. We further elucidate the technical and structural details of a comprehensive data repository-the HM COVID-19 Surveillance and Outcomes Registry (CURATOR). We particularly highlight how CURATOR conforms to standard health care digitization principles in the LHC context.

Results: The HM COVID-19 RRTF comprises expertise in epidemiology, health systems, clinical domains, data sciences, information technology, and research regulation. The RRTF initially convened in March 2020 to prioritize and streamline COVID-19 observational research; to date, it has reviewed over 60 protocols and made recommendations to the institutional review board (IRB). The RRTF also established the charter for CURATOR, which in itself was IRB-approved in April 2020. CURATOR is a relational structured query language database that is directly populated with data from electronic health records, via largely automated extract, transform, and load procedures. The CURATOR design enables longitudinal tracking of COVID-19 cases and controls before and after COVID-19 testing. CURATOR has been set up following the SSoT principle and is harmonized across other COVID-19 data sources. CURATOR eliminates data silos by leveraging unique and disparate big data sources for COVID-19 research and provides a platform to capitalize on institutional investment in cloud computing. It currently hosts deeply phenotyped sociodemographic, clinical, and outcomes data of approximately 200,000 individuals tested for COVID-19. It supports more than 30 IRB-approved protocols across several clinical domains and has generated numerous publications from its core and associated data sources.

Conclusions: A data-driven decision-making strategy is paramount to the success of health care organizations. Investment in cross-disciplinary expertise, health care technology, and leadership commitment are key ingredients to foster an LHC system. Such systems can mitigate the effects of ongoing and future health care catastrophes by providing timely and validated decision support.
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http://dx.doi.org/10.2196/26773DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7903978PMC
February 2021

Sex differences in susceptibility, severity, and outcomes of coronavirus disease 2019: Cross-sectional analysis from a diverse US metropolitan area.

PLoS One 2021 13;16(1):e0245556. Epub 2021 Jan 13.

Department of Neurology, McGovern Medical School, UTHealth, Houston, TX, United States of America.

Introduction: Sex is increasingly recognized as an important factor in the epidemiology and outcome of many diseases. This also appears to hold for coronavirus disease 2019 (COVID-19). Evidence from China and Europe has suggested that mortality from COVID-19 infection is higher in men than women, but evidence from US populations is lacking. Utilizing data from a large healthcare provider, we determined if males, as compared to females have a higher likelihood of SARS-CoV-2 susceptibility, and if among the hospitalized COVID-19 patients, male sex is independently associated with COVID-19 severity and poor in-hospital outcomes.

Methods And Findings: Using the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guidelines, we conducted a cross-sectional analysis of data from a COVID-19 Surveillance and Outcomes Registry (CURATOR). Data were extracted from Electronic Medical Records (EMR). A total of 96,473 individuals tested for SARS-CoV-2 RNA in nasopharyngeal swab specimens via Polymerized Chain Reaction (PCR) tests were included. For hospital-based analyses, all patients admitted during the same time-period were included. Of the 96,473 patients tested, 14,992 (15.6%) tested positive, of whom 4,785 (31.9%) were hospitalized and 452 (9.5%) died. Among all patients tested, men were significantly older. The overall SARS-CoV-2 positivity among all tested individuals was 15.5%, and was higher in males as compared to females 17.0% vs. 14.6% [OR 1.20]. This sex difference held after adjusting for age, race, ethnicity, marital status, insurance type, median income, BMI, smoking and 17 comorbidities included in Charlson Comorbidity Index (CCI) [aOR 1.39]. A higher proportion of males (vs. females) experienced pulmonary (ARDS, hypoxic respiratory failure) and extra-pulmonary (acute renal injury) complications during their hospital course. After adjustment, length of stay (LOS), need for mechanical ventilation, and in-hospital mortality were significantly higher in males as compared to females.

Conclusions: In this analysis of a large US cohort, males were more likely to test positive for COVID-19. In hospitalized patients, males were more likely to have complications, require ICU admission and mechanical ventilation, and had higher mortality than females, independent of age. Sex disparities in COVID-19 vulnerability are present, and emphasize the importance of examining sex-disaggregated data to improve our understanding of the biological processes involved to potentially tailor treatment and risk stratify patients.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0245556PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7806140PMC
January 2021

Pediatric asthma hospitalization: individual and environmental characteristics of high utilizers in South Texas.

J Asthma 2020 Oct 8:1-11. Epub 2020 Oct 8.

Department of Environmental and Occupational Health, School of Public Health, Texas A&M University, College Station, TX, USA.

Objective: Few studies have examined factors affecting the high frequency of hospitalization for pediatric asthma. This study identifies individual and environmental characteristics of children with asthma from a low-income community with a high number of hospitalizations.

Methods: The study population included 902 children admitted at least once to a children's hospital in South Texas because of asthma from 2010 to 2016. The population was divided into three groups by utilization frequency (high: ≥4 times, medium: 2-3 times, or low: 1 time). Individual-level factors at index admission and environmental factors were included for the analysis. Unadjusted and adjusted multivariate ordered logistic regression models were applied to identify significant characteristics of high hospital utilizers.

Results: The high utilization group comprised 2.4% of total patients and accounted for substantial hospital resource utilization: 10.8% of all admissions and 13.5% of days stayed in the hospital. Patients in the high utilization group showed longer length of stay (LOS) and shorter time between admissions on average than the other two groups. The multivariate ordered logistic regression models revealed that age of 5-11 years (OR = 0.57, 95%CI = 0.35-0.93), longer LOS (2 days: OR = 1.80, 95%CI = 1.15-2.84; ≥3 days: OR = 3.38, 95%CI = 2.10-5.46), warm season at index admission (OR = 1.49, 95%CI = 1.01-2.20), and higher average ozone level in children's residential neighborhoods (OR = 1.78, 95%CI = 1.01-3.14) were significantly associated with a higher number of asthma hospitalizations.

Conclusions: The findings suggest the importance of monitoring high hospital utilizers and establishing strategies for such patients based on their characteristics to reduce repeated hospitalizations and to increase optimal use of hospital resources.
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http://dx.doi.org/10.1080/02770903.2020.1827424DOI Listing
October 2020

Racial and ethnic disparities in SARS-CoV-2 pandemic: analysis of a COVID-19 observational registry for a diverse US metropolitan population.

BMJ Open 2020 08 11;10(8):e039849. Epub 2020 Aug 11.

Center for Outcomes Research, Houston Methodist Research Institute, Houston, Texas, USA.

Introduction: Data on race and ethnic disparities for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection are limited. We analysed sociodemographic factors associated with higher likelihood of SARS-CoV-2 infection and explore mediating pathways for race and ethnic disparities in the SARS-CoV-2 pandemic.

Methods: This is a cross-sectional analysis of the COVID-19 Surveillance and Outcomes Registry, which captures data for a large healthcare system, comprising one central tertiary care hospital, seven large community hospitals and an expansive ambulatory/emergency care network in the Greater Houston area. Nasopharyngeal samples for individuals inclusive of all ages, races, ethnicities and sex were tested for SARS-CoV-2. We analysed sociodemographic (age, sex, race, ethnicity, household income, residence population density) and comorbidity (Charlson Comorbidity Index, hypertension, diabetes, obesity) factors. Multivariable logistic regression models were fitted to provide adjusted OR (aOR) and 95% CI for likelihood of a positive SARS-CoV-2 test. Structural equation modelling (SEM) framework was used to explore three mediation pathways (low income, high population density, high comorbidity burden) for the association between non-Hispanic black (NHB) race, Hispanic ethnicity and SARS-CoV-2 infection.

Results: Among 20 228 tested individuals, 1551 (7.7%) tested positive. The overall mean (SD) age was 51.1 (19.0) years, 62% were females, 22% were black and 18% were Hispanic. NHB and Hispanic ethnicity were associated with lower socioeconomic status and higher population density residence. In the fully adjusted model, NHB (vs non-Hispanic white; aOR, 2.23, CI 1.90 to 2.60) and Hispanic ethnicity (vs non-Hispanic; aOR, 1.95, CI 1.72 to 2.20) had a higher likelihood of infection. Older individuals and males were also at higher risk of infection. The SEM framework demonstrated a significant indirect effect of NHB and Hispanic ethnicity on SARS-CoV-2 infection mediated via a pathway including residence in densely populated zip code.

Conclusions: There is strong evidence of race and ethnic disparities in the SARS-CoV-2 pandemic that are potentially mediated through unique social determinants of health.
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http://dx.doi.org/10.1136/bmjopen-2020-039849DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7418666PMC
August 2020

Effect of Ambient Air Pollution on Hospital Readmissions among the Pediatric Asthma Patient Population in South Texas: A Case-Crossover Study.

Int J Environ Res Public Health 2020 07 6;17(13). Epub 2020 Jul 6.

Department of Environmental and Occupational Health, School of Public Health, Texas A&M University, College Station, TX 77843, USA.

Few studies have evaluated the association between ambient air pollution and hospital readmissions among children with asthma, especially in low-income communities. This study examined the short-term effects of ambient air pollutants on hospital readmissions for pediatric asthma in South Texas. A time-stratified case-crossover study was conducted using the hospitalization data from a children's hospital and the air pollution data, including particulate matter 2.5 (PM) and ozone concentrations, from the Centers for Disease Control and Prevention between 2010 and 2014. A conditional logistic regression analysis was performed to investigate the association between ambient air pollution and hospital readmissions, controlling for outdoor temperature. We identified 111 pediatric asthma patients readmitted to the hospital between 2010 and 2014. The single-pollutant models showed that PM concentration had a significant positive effect on risk for hospital readmissions (OR = 1.082, 95% CI = 1.008-1.162, = 0.030). In the two-pollutant models, the increased risk of pediatric readmissions for asthma was significantly associated with both elevated ozone (OR = 1.023, 95% CI = 1.001-1.045, = 0.042) and PM concentrations (OR = 1.080, 95% CI = 1.005-1.161, = 0.036). The effects of ambient air pollutants on hospital readmissions varied by age and season. Our findings suggest that short-term (4 days) exposure to air pollutants might increase the risk of preventable hospital readmissions for pediatric asthma patients.
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http://dx.doi.org/10.3390/ijerph17134846DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7370127PMC
July 2020

Association between Ambient Air Pollution and Hospital Length of Stay among Children with Asthma in South Texas.

Int J Environ Res Public Health 2020 05 27;17(11). Epub 2020 May 27.

Department of Environmental and Occupational Health, School of Public Health, Texas A&M University, College Station, TX 77843, USA.

Although hospital length of stay (LOS) has been identified as a proxy measure of healthcare expenditures in the United States, there are limited studies investigating the potentially important association between outdoor air pollution and LOS for pediatric asthma. This study aims to examine the effect of ambient air pollution on LOS among children with asthma in South Texas. It included retrospective data on 711 children aged 5-18 years old admitted for asthma to a pediatric tertiary care hospital in South Texas between 2010 and 2014. Air pollution data including particulate matter (PM) and ozone were collected from the U.S. Centers for Disease Control and Prevention. The multivariate binomial logistic regression analyses were performed to determine the association between each air pollutant and LOS, controlling for confounders. The regression models showed the increased ozone level was significantly associated with prolonged LOS in the single- and two-pollutant models ( < 0.05). Furthermore, in the age-stratified models, PM was positively associated with LOS among children aged 5-11 years old ( < 0.05). In conclusion, this study revealed a concerning association between ambient air pollution and LOS for pediatric asthma in South Texas.
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http://dx.doi.org/10.3390/ijerph17113812DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7312124PMC
May 2020

Improving the cost, quality, and safety of perioperative care: A systematic review of the literature on implementation of the perioperative surgical home.

J Clin Anesth 2020 Aug 11;63:109760. Epub 2020 Apr 11.

Analytics and Research Services, American Society of Anesthesiologists, 1061 American Lane, Schaumburg, IL 60173-4973, USA.

Study Objective: The perioperative surgical home (PSH) is a recent innovation in perioperative care delivery that coordinates the pre-, intra-, and post-operative elements of surgical care under one organizational umbrella. Although significant research supports the efficacy of individual elements of the PSH in improving outcomes, there is not a published systematic review of the efficacy of entire PSH programs in improving patient outcomes. This article summarizes descriptions of PSH programs available in the literature and examines outcomes of original studies of PSH implementation.

Design: We conducted a systematic literature review to identify relevant articles on PSH implementation and synthesize our findings.

Setting: The studies included in our review took place at multiple academic and community hospitals in the United States.

Patients: Patients involved in the PSH studies included surgical patients of various ages and ASA classifications in various surgical specialties.

Interventions: All studies included in our review involved the implementation of a PSH program.

Measurements: Outcomes examined include length of stay, postoperative recovery, readmission rates, and patient discharge destination, among others.

Main Results: We identified 11 studies of PSH implementation that met our inclusion and exclusion criteria. Most PSH programs described in these studies included an emphasis on preoperative education, standardization of care protocols in all phases of surgery, use of opioid-sparing multimodal analgesia, and collaborative staffing models. PSH program implementation was often associated with decreased length of stay, decreased utilization of postoperative opioids, decreased utilization of the ICU, and increased probability of discharge to home. PSH implementation was not meaningfully associated with reductions in readmission rates. Findings for cost reductions following PSH implementation were mixed.

Conclusions: Early evidence indicates that through elements that emphasize care coordination, standardization, and patient-centeredness, PSH programs can improve patient postoperative recovery outcomes and decrease hospital utilization.
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http://dx.doi.org/10.1016/j.jclinane.2020.109760DOI Listing
August 2020

An exploration of community partnerships, safety-net hospitals, and readmission rates.

Health Serv Res 2020 08 5;55(4):531-540. Epub 2020 Apr 5.

Center for Outcomes Research, Houston Methodist Research Institute, Houston, Texas.

Objective: To compare hospital-community partnerships among safety-net hospitals relative to non-safety-net hospitals, and explore whether hospital-community partnerships are associated with reductions in readmission rates.

Data Sources: Data from four nationwide hospital-level datasets for 2015-2016, including American Hospital Association (AHA) annual survey, Hospital Inpatient Prospective Payment System (IPPS) data, CMS Hospital Compare, and County Health Rankings National (CHRN) data.

Study Design: We first examined how safety-net hospitals partner with nine different community providers, and how the overall and individual partnership patterns differ from those in non-safety-net hospitals. We then explored their association with 30-day readmission rates by diagnosis and hospital wide.

Data Collection/extraction Methods: We included 1979 hospitals across 50 US states.

Principal Findings: Safety-net hospitals were more engaged in hospital-community partnerships, especially with local public health, local governments, social services, nonprofits, and insurance companies, relative to their non-safety-net peers. However, we found that such partnerships were not significantly related to reductions in readmission rates. The findings indicated that merely partnering with various community organizations may not be associated with readmission rate reduction.

Conclusions: Before promoting partnerships with various community organizations for its own sake, further prospective, longitudinal, and evidence-based guidance derived from the study of hospital-community partnerships is needed to make meaningful recommendations aimed at readmission rate reduction in safety-net hospitals.
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http://dx.doi.org/10.1111/1475-6773.13287DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7376002PMC
August 2020

Variation and Disparities in Awareness of Myocardial Infarction Symptoms Among Adults in the United States.

JAMA Netw Open 2019 12 2;2(12):e1917885. Epub 2019 Dec 2.

Division of Cardiovascular Prevention and Wellness, Houston Methodist DeBakey Heart and Vascular Center, Houston, Texas.

Importance: Prompt recognition of myocardial infarction symptoms is critical for timely access to lifesaving emergency cardiac care. However, patients with myocardial infarction continue to have a delayed presentation to the hospital.

Objective: To understand the variation and disparities in awareness of myocardial infarction symptoms among adults in the United States.

Design, Setting, And Participants: This cross-sectional study used data from the 2017 National Health Interview Survey among adult residents of the United States, assessing awareness of the 5 following common myocardial infarction symptoms among different sociodemographic subgroups: (1) chest pain or discomfort, (2) shortness of breath, (3) pain or discomfort in arms or shoulders, (4) feeling weak, lightheaded, or faint, and (5) jaw, neck, or back pain. The response to a perceived myocardial infarction (ie, calling emergency medical services vs other) was also assessed.

Main Outcomes And Measures: Prevalence and characteristics of individuals who were unaware of myocardial infarction symptoms and/or chose not to call emergency medical services in response to these symptoms.

Results: Among 25 271 individuals (13 820 women [51.6%; 95% CI, 50.8%-52.4%]; 17 910 non-Hispanic white individuals [69.9%; 95% CI, 68.2%-71.6%]; and 21 826 individuals [82.7%; 95% CI, 81.5%-83.8%] born in the United States), 23 383 (91.8%; 95% CI, 91.0%-92.6%) considered chest pain or discomfort a symptom of myocardial infarction; 22 158 (87.0%; 95% CI, 86.1%-87.8%) considered shortness of breath a symptom; 22 064 (85.7%; 95% CI, 84.8%-86.5%) considered pain or discomfort in arm a symptom; 19 760 (77.0%; 95% CI, 76.1%-77.9%) considered feeling weak, lightheaded, or faint a symptom; and 16 567 (62.6%; 95% CI, 61.6%-63.7%) considered jaw, neck, or back pain a symptom. Overall, 14 075 adults (53.0%; 95% CI, 51.9%-54.1%) were aware of all 5 symptoms, whereas 4698 (20.3%; 95% CI, 19.4%-21.3%) were not aware of the 3 most common symptoms and 1295 (5.8%; 95% CI, 5.2%-6.4%) were not aware of any symptoms. Not being aware of any symptoms was associated with male sex (odds ratio [OR], 1.23; 95% CI, 1.05-1.44; P = .01), Hispanic ethnicity (OR, 1.89; 95% CI, 1.47-2.43; P < .001), not having been born in the United States (OR, 1.85; 95% CI, 1.47-2.33; P < .001), and having a lower education level (OR, 1.31; 95% CI, 1.09-1.58; P = .004). Among 294 non-Hispanic black or Hispanic individuals who were not born in the United States, belonged to the low-income or lowest-income subgroup, were uninsured, and had a lower education level, 61 (17.9%; 95% CI, 13.3%-23.6%) were not aware of any symptoms. This group had 6-fold higher odds of not being aware of any symptoms (OR, 6.34; 95% CI, 3.92-10.26; P < .001) compared with individuals without these characteristics. Overall, 1130 individuals (4.5%; 95% CI, 4.0%-5.0%) chose a different response than calling emergency medical services in response to a myocardial infarction.

Conclusions And Relevance: Many adults in the United States remain unaware of the symptoms of and appropriate response to a myocardial infarction. In this study, several sociodemographic subgroups were associated with a higher risk of not being aware. They may benefit the most from targeted public health initiatives.
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http://dx.doi.org/10.1001/jamanetworkopen.2019.17885DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6991230PMC
December 2019

Cost-Related Medication Nonadherence in Adults With Atherosclerotic Cardiovascular Disease in the United States, 2013 to 2017.

Circulation 2019 12 25;140(25):2067-2075. Epub 2019 Nov 25.

Division of Cardiovascular Prevention and Wellness Houston Methodist DeBakey Heart & Vascular Center & Center for Outcomes Research Houston Methodist, Houston, TX (K.N.).

Background: Medication nonadherence is associated with worse outcomes in patients with atherosclerotic cardiovascular disease (ASCVD), a group who requires long-term therapy for secondary prevention. It is important to understand to what extent drug costs, which are potentially actionable factors, contribute to medication nonadherence.

Methods: In a nationally representative survey of US adults in the National Health Interview Survey (2013-2017), we identified individuals ≥18 years with a reported history of ASCVD. Participants were considered to have experienced cost-related nonadherence (CRN) if in the preceding 12 months they reported skipping doses to save money, taking less medication to save money, or delaying filling a prescription to save money. We used survey analysis to obtain national estimates.

Results: Of the 14 279 surveyed individuals with ASCVD, a weighted 12.6% (or 2.2 million [95% CI, 2.1-2.4]) experienced CRN, including 8.6% or 1.5 million missing doses, 8.8% or 1.6 million taking lower than prescribed doses, and 10.5% or 1.9 million intentionally delaying a medication fill to save costs. Age <65 years, female sex, low family income, lack of health insurance, and high comorbidity burden were independently associated with CRN, with >1 in 5 reporting CRN in these subgroups. Survey respondents with CRN compared with those without CRN had 10.8-fold higher odds of requesting low-cost medications and 8.9-fold higher odds of using alternative, nonprescription, therapies.

Conclusions: One in 8 patients with ASCVD reports nonadherence to medications because of cost. The removal of financial barriers to accessing medications, particularly among vulnerable patient groups, may help improve adherence to essential therapy to reduce ASCVD morbidity and mortality.
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http://dx.doi.org/10.1161/CIRCULATIONAHA.119.041974DOI Listing
December 2019

Post-bariatric surgery lab tests: are they excessive and redundant?

Surg Endosc 2020 10 1;34(10):4626-4631. Epub 2019 Nov 1.

Department of Surgery, Houston Methodist, 6550 Fannin Street, Smith Tower, Suite 1601, Houston, TX, 77030, USA.

Introduction: Following bariatric surgery, ongoing postoperative testing is required to measure nutritional deficiencies; the purpose of this study was to quantify the prevalence of these nutritional deficiencies based on two-year follow-up tests at recommended time points.

Methods And Procedures: A retrospective data analysis was conducted of all laboratory tests for bariatric patients who underwent surgery between May 2016 and January 2018 with available lab data (n = 397). Results for nine different nutritional labs were categorized into six recommended postoperative time periods based on time elapsed since the procedure date. Binary variables were created for each laboratory result to calculate descriptive statistics of abnormalities for each lab test over time and used in the individual GEE logistic regression models. Grouped logistic regression examined the total nutritional deficiencies of the nine combined nutrients considering total available labs.

Results: Multiple lab tests indicated a very low frequency of abnormalities (e.g., Vitamin A, Vitamin B12, Copper, and Folate). Many of the nine included nutritional labs had an average deficiency of less than 10% across all time points. The grouped logistic model found preoperative nutritional deficiency to be predictive of postoperative nutritional deficiency (OR 3.70, p < 0.001).

Conclusions: We found the vast majority of routine lab test results to be normal at multiple time points. Current practice can add up to significant lab expenses over time. The frequency of postoperative testing in this population may be redundant and of very little value. Unnecessary follow-up laboratory testing costs the patients and the health care system in both time and resources. Patients with preoperative deficiencies appear to be at higher risk for nutritional deficiencies when compared to bariatric surgery patients that did not have preoperative nutritional deficiencies. Future research should focus on defining cost effective postoperative lab testing guidelines for at risk bariatric patients.
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http://dx.doi.org/10.1007/s00464-019-07216-9DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7525273PMC
October 2020

The Association Between State-Level Health Information Exchange Laws and Hospital Participation in Community Health Information Organizations.

AMIA Annu Symp Proc 2018 5;2018:313-320. Epub 2018 Dec 5.

Indiana University Richard M. Fairbanks School of Public Health, Indianapolis, IN, USA.

Evidence suggests that health information exchange (HIE) is an effective strategy to improve efficiency and quality of care, as well as reduce costs. A complex patchwork of federal and state legislation has developed over time to encourage HIE activity. Hospitals and health systems have adopted various HIE models to meet the requirements of these statutes and regulations. Given the complexity of HIE laws, it is important to understand how these legal levers influence HIE engagement. We combined data from two unique data sources to examine the association between state-level HIE laws and hospital engagement in community HIEs. Our results identified three legal provisions of state laws (HIE authorization, financial & non-financial incentives, opt-out consent) that increased the likelihood of community HIE engagement. Other provisions decreased the likelihood of engagement. This analysis provides foundational evidence about the utility of HIE laws. More research is needed to determine causal relationships.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6371387PMC
October 2019

Quality indicators to measure the effect of opioid stewardship interventions in hospital and emergency department settings.

Am J Health Syst Pharm 2019 Feb;76(4):225-235

Department of Neurology, Houston Methodist Hospital, Houston, TX.

Purpose: The purpose of this project was to develop a set of valid and feasible quality indicators used to track opioid stewardship efforts in hospital and emergency department settings.

Methods: Candidate quality indicators were extracted from published literature. Feasibility screening excluded quality indicators that cannot be reliably extracted from the electronic health record or that are irrelevant to pain management in the hospital and emergency department settings. Validity screening used an electronic survey of key stakeholders including pharmacists, nurses, physicians, administrators, and researchers. Stakeholders used a 9-point Likert scale to rate the validity of each quality indicator based on predefined criteria. During expert panel discussions, stakeholders revised quality indicator wording, added new quality indicators, and voted to include or exclude each quality indicator. Priority ranking used a second electronic survey and a 9-point Likert scale to prioritize the included quality indicators.

Results: Literature search yielded 76 unique quality indicators. Feasibility screening excluded 9 quality indicators. The validity survey was completed by 46 (20%) of 228 stakeholders. Expert panel discussions yielded 19 valid and feasible quality indicators. The top 5 quality indicators by priority were: the proportion of patients with (1) naloxone administrations, (2) as needed opioids with duplicate indications, and (3) long acting or extended release opioids if opioid-naïve, (4) the average dose of morphine milligram equivalents administered per day, and (5) the proportion of opioid discharge prescriptions exceeding 7 days.

Conclusion: Multi-professional stakeholders across a health system participated in this consensus process and developed a set of 19 valid and feasible quality indicators for opioid stewardship interventions in the hospital and emergency department settings.
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http://dx.doi.org/10.1093/ajhp/zxy042DOI Listing
February 2019

How Leading Hospitals Operationalize Evidence-Based Readmission Reduction Strategies: A Mixed-Methods Comparative Study Using Systematic Review and Survey Design.

Am J Med Qual 2019 Nov/Dec;34(6):529-537. Epub 2019 Feb 4.

Houston Methodist Hospital, Houston, TX.

Although various interventions targeted at reducing hospital readmissions have been identified in the literature, little is known about actual operationalization of such evidence-based interventions. This study conducted a systematic review and a survey of key informants in 2 leading hospitals, Houston Methodist (HM) and MD Anderson Cancer Center (MDACC), to compare and contrast the most cited evidence-based interventions in the current literature with interventions reported by those hospitals. The authors found that both hospitals followed evidence-based practices reported as successful in the literature. Both hospitals have implemented interventions for inpatient settings, and the timing of interventions was very similar. Major implementation differences observed for post-discharge interventions focused on collaboration. It also was found that HM was more likely than MDACC to use medication reconciliation in outpatient ( = .018) and discharge planning for community/home patients ( = .032). Results will provide hospital professionals with insights for implementing the most effective interventions to reduce readmissions.
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http://dx.doi.org/10.1177/1062860618824410DOI Listing
April 2020

Remote Patient Monitoring and Telemedicine in Neonatal and Pediatric Settings: Scoping Literature Review.

J Med Internet Res 2018 12 20;20(12):e295. Epub 2018 Dec 20.

Division of Pediatric Surgery, Texas Children's Hospital, Houston, TX, United States.

Background: Telemedicine and telehealth solutions are emerging rapidly in health care and have the potential to decrease costs for insurers, providers, and patients in various settings. Pediatric populations that require specialty care are disadvantaged socially or economically or have chronic health conditions that will greatly benefit from results of studies utilizing telemedicine technologies. This paper examines the emerging trends in pediatric populations as part of a systematic literature review and provides a scoping review of the type, extent, and quantity of research available.

Objective: This paper aims to examine the role of remote patient monitoring (RPM) and telemedicine in neonatal and pediatric settings. Findings can be used to identify strengths, weaknesses, and gaps in the field. The identification of gaps will allow for interventions or research to improve health care quality and costs.

Methods: A systematic literature review is being conducted to gather an adequate amount of relevant research for telehealth in pediatric populations. The fields of RPM and telemedicine are not yet very well established by the health care services sector, and definitions vary across health care systems; thus, the terms are not always defined similarly throughout the literature. Three databases were scoped for information for this specific review, and 56 papers were included for review.

Results: Three major telemedicine trends emerged from the review of 45 relevant papers-RPM, teleconsultation, and monitoring patients within the hospital, but without contact-thus, decreasing the likelihood of infection or other adverse health effects.

Conclusions: While the current telemedicine approaches show promise, limited studied conditions and small sample sizes affect generalizability, therefore, warranting further research. The information presented can inform health care providers of the most widely implemented, studied, and effective forms of telemedicine for patients and their families and the telemedicine initiatives that are most cost efficient for health systems. While the focus of this review is to summarize some telehealth applications in pediatrics, we have also presented research studies that can inform providers about the importance of data sharing of remote monitoring data between hospitals. Further reports will be developed to inform health systems as the systematic literature review continues.
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http://dx.doi.org/10.2196/jmir.9403DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6320401PMC
December 2018

The four Ps of patient experience: A new strategic framework informed by theory and practice.

Health Mark Q 2018 Oct-Dec;35(4):313-325. Epub 2018 Dec 14.

a NSF Center for Health Organization Transformation , Texas A&M University , College Station , TX , USA.

This article proposes a new strategic framework to assist healthcare organizations in achieving great patient experiences in the healthcare setting. We synthesize models of practice and literature relevant to the patient experience in order to propose the four Ps of patient experience. Key levers used in this model are: (a) trained autonomous physicians, (b) multidisciplinary partners, (c) alternative places of care delivery matched to patient conditions and needs, and (d) standardized yet flexible processes. Healthcare leaders will be able to use the proposed framework to develop detailed strategies toward improving patient satisfaction and experiences.
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http://dx.doi.org/10.1080/07359683.2018.1524598DOI Listing
May 2019

Measuring Team Effectiveness in the Health Care Setting: An Inventory of Survey Tools.

Health Serv Insights 2018 24;11:1178632918796230. Epub 2018 Aug 24.

Health Policy Research, American Society of Anesthesiologists, Schaumburg, IL, USA.

Background: Guidance for measuring team effectiveness in dynamic clinical settings is necessary; however, there are no consensus strategies to help health care organizations achieve optimal teamwork. This systematic review aims to identify validated survey instruments of team effectiveness by clinical settings.

Methods: PubMed, MEDLINE, and ISI Web of Knowledge were searched for team effectiveness surveys deployed from 1990 to 2016. Validity and reliability were evaluated using 4 psychometric properties: interrater agreement, internal consistency, content validity, and structural integrity. Two conceptual frameworks, the Donabedian model and the Command Team Effectiveness model, assess conceptual dimensions most measured in each health care setting.

Results: The 22 articles focused on surgical, primary care, and other health care settings. Few instruments report the required psychometric properties or feature non-self-reported outcomes. The major conceptual dimensions measured in the survey instruments differed across settings. Team cohesion and overall perceived team effectiveness can be found in all the team effectiveness measurement tools regardless of the health care setting. We found that surgical settings have distinctive conditions for measuring team effectiveness relative to primary or ambulatory care.

Discussion: Further development of setting-specific team effectiveness measurement tools can help further enhance continuous quality improvements and clinical outcomes in the future.
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http://dx.doi.org/10.1177/1178632918796230DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6109848PMC
August 2018

The Diabetes Management Education Program in South Texas: An Economic and Clinical Impact Analysis.

Front Public Health 2017 18;5:345. Epub 2017 Dec 18.

School of Public Health, Texas A&M University, College Station, TX, United States.

Introduction: Diabetes is a major chronic disease that can lead to serious health problems and high healthcare costs without appropriate disease management and treatment. In the United States, the number of people diagnosed with diabetes and the cost for diabetes treatment has dramatically increased over time. To improve patients' self-management skills and clinical outcomes, diabetes management education (DME) programs have been developed and operated in various regions.

Objective: This community case study explores and calculates the economic and clinical impacts of expanding a model DME program into 26 counties located in South Texas.

Methods: The study sample includes 355 patients with type 2 diabetes and a follow-up hemoglobin A1c level measurement among 1,275 individuals who participated in the DME program between September 2012 and August 2013. We used the Gilmer's cost differentials model and the United Kingdom Prospective Diabetes Study (UKPDS) Risk Engine methodology to predict 3-year healthcare cost savings and 10-year clinical benefits of implementing a DME program in the selected 26 Texas counties.

Results: Changes in estimated 3-year cost and the estimated treatment effect were based on baseline hemoglobin A1c level. An average 3-year reduction in medical treatment costs per program participant was $2,033 (in 2016 dollars). The total healthcare cost savings for the 26 targeted counties increases as the program participation rate increases. The total projected cost saving ranges from $12 million with 5% participation rate to $185 million with 75% participation rate. A 10-year outlook on additional clinical benefits associated with the implementation and expansion of the DME program at 60% participation is estimated to result in approximately 4,838 avoided coronary heart disease cases and another 392 cases of avoided strokes.

Conclusion: The implementation of this model DME program in the selected 26 counties would contribute to substantial healthcare cost savings and clinical benefits. Organizations that provide DME services may benefit from reduction in medical treatment costs and improvement in clinical outcomes for populations with diabetes.
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http://dx.doi.org/10.3389/fpubh.2017.00345DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5741603PMC
December 2017

Editorial.

Authors:
Bita A Kash

J Healthc Manag 2017 Nov/Dec;62(6):356-357

Editor.

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http://dx.doi.org/10.1097/JHM-D-17-00162DOI Listing
June 2019

Falling short: how state laws can address health information exchange barriers and enablers.

J Am Med Inform Assoc 2018 06;25(6):635-644

Center for Health Organization Transformation, Department of Health Policy and Management, School of Public Health, Texas A&M University, College Station, TX, USA.

Objective: Research on the implementation of health information exchange (HIE) organizations has identified both positive and negative effects of laws relating to governance, incentives, mandates, sustainability, stakeholder participation, patient engagement, privacy, confidentiality, and security. We fill a substantial research gap by describing whether comprehensive state and territorial HIE legal frameworks address identified legal facilitators and barriers.

Materials And Methods: We used the Westlaw database to identify state and territorial laws relating to HIEs in effect on June 7, 2016 (53 jurisdictions). We blind-coded all laws and addressed coding discrepancies in peer-review meetings. We recorded a consensus code for each law in a master database. We compared 20 HIE legal attributes with identified barriers to and enablers of HIE activity in the literature.

Results: Forty-two states, the District of Columbia, and 2 territories have laws relating to HIEs. On average, jurisdictions address 8.32 of the 20 criteria selected in statutes and regulations. Twenty jurisdictions unambiguously address ≤5 criteria in statutes and regulations. None of the significant legal criteria are unambiguously addressed in >60% of the 53 jurisdictions.

Discussion: Laws can be barriers to or enablers of HIEs. However, jurisdictions are not addressing many significant issues identified by researchers. Consequently, there is a substantial risk that existing legal frameworks are not adequately supporting HIEs.

Conclusion: The current evidence base is insufficient for comparative assessments or impact rankings of the various factors. However, the detailed Centers for Disease Control and Prevention dataset of HIE laws could enable investigations into the types of laws that promote or impede HIEs.
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http://dx.doi.org/10.1093/jamia/ocx122DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7646865PMC
June 2018

Editorial.

Authors:
Bita A Kash

J Healthc Manag 2017 Sep/Oct;62(5):287-288

Editor.

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http://dx.doi.org/10.1097/JHM-D-17-00127DOI Listing
July 2018

Editorial.

Authors:
Bita A Kash

J Healthc Manag 2017 Jul/Aug;62(4):223-224

Editor.

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http://dx.doi.org/10.1097/JHM-D-17-00095DOI Listing
July 2018

Review of successful hospital readmission reduction strategies and the role of health information exchange.

Int J Med Inform 2017 08 20;104:97-104. Epub 2017 May 20.

The University of Texas Health Science Center, Houston, TX, USA. Electronic address:

Context: The United States has invested substantially in technologies that enable health information exchange (HIE), which in turn can be deployed to reduce avoidable hospital readmission rates in many communities. With avoidable hospital readmissions as the primary focus, this study profiles successful hospital readmission rate reduction initiatives that integrate HIE as a strategy. We hypothesized that the use of HIE is associated with decreased hospital readmissions beyond other observed population health benefits. Results of this systematic review are used to describe and profile successful readmission reduction programs that integrate HIE as a tool.

Methods: A systematic review of literature provided an understanding of the use of HIE as a strategy to reduce hospital readmission rates. We conducted a review of 4,862 citations written in English about readmission reduction strategies from January 2006 to September 2016 in the MEDLINE-PubMed database. Of these, 106 studies reported 30-day readmission rates as an outcome and only 13 articles reported using HIE.

Results: Only a very small number (12%) of hospitals incorporated HIE as a primary tool for evidence-based readmission reduction initiatives. Information exchange between providers has been suggested to play a key role in reducing avoidable readmission rates, yet there is not currently evidence supporting current HIE-enabled readmission initiatives. Most successful readmission reduction programs demonstrate collaboration with primary care providers to augment transitions of care to existing care management functions without additional staff while using effective information exchange capabilities.

Conclusions: This research confirms there is very little integration of HIE into health systems readmissions initiatives. There is a great opportunity to achieve population health targets using the HIE infrastructure. Hospitals should consider partnering with primary care clinics to implement multifaceted transitions of care programs to significantly reduce 30-day readmission rates.
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http://dx.doi.org/10.1016/j.ijmedinf.2017.05.012DOI Listing
August 2017

Editorial.

Authors:
Bita A Kash

J Healthc Manag 2017 May/Jun;62(3):153-154

Editor.

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http://dx.doi.org/10.1097/JHM-D-17-00055DOI Listing
October 2017

Psychological Distress and the Use of Clinical Preventive Services by Community-Dwelling Older Adults.

J Appl Gerontol 2019 05 1;38(5):599-616. Epub 2017 Feb 1.

1 Texas A&M University, College Station, USA.

In this study, we explored whether psychological distress plays a role in the use of recommended clinical preventive services among community-dwelling older adults. The sample is drawn from respondents 65 years and older who participated in the 2011 Medical Expenditure Panel Survey (MEPS). Logistic regressions with selected covariates were entered in the model to estimate odds ratios (OR) with 95% confidence interval (CI) for the independent effect of psychological distress on the utilization of each of five preventive services. With the exception of breast cancer screening where the uptake of preventive services was significantly lower for older adults with psychological distress (OR = 0.57, p < .001), uptake of other key preventive measures revealed no significant utilization differences between older adults with and without psychological distress. The results suggest that adherence to breast cancer screening guidelines may be increased by improving recognition and treatment of emotional health problems in older women.
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http://dx.doi.org/10.1177/0733464817693376DOI Listing
May 2019

Editorial.

Authors:
Bita A Kash

J Healthc Manag 2017 Mar/Apr;62(2):79-80

Editor.

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http://dx.doi.org/10.1097/JHM-D-17-00016DOI Listing
October 2017

EDITORIAL.

Authors:
Bita A Kash

J Healthc Manag 2016 Jul/Aug;61(4):243-244

Editor.

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November 2017

Enhanced Transitions of Care: Centralizing Discharge Phone Calls Improves Ability to Reach Patients and Reduces Hospital Readmissions.

J Healthc Qual 2017 Mar/Apr;39(2):e10-e21

Background: The discharge phone call (DPC) is an important initiative aimed at improving transitions of care and reducing readmissions. It is of added importance as financial penalties will be imposed on hospitals with "excessive" Medicare readmissions. This study examines the impact of DPCs on percentages of patients reached through the DPCs and hospital readmission rates based on the centralized or noncentralized mode of DPCs.

Methods: The health system centralized the Studer Group Discharge Phone Call program into one central call center with the goals of reaching more discharged patients and to ultimately reduce hospital readmissions. The study analyzed hospital visits from 74,754 patient admissions that could result in an unplanned hospital readmission. Hospital discharge data were analyzed from August 2010 to January 2014. Primary outcomes included DPCs reaching discharged patients and effects on hospital readmission rates as a result of centralizing the DPC program.

Results: Centralized DPCs are significantly associated with increases in the percentage of patients reached by the DPC, which in turn reduces readmissions rates. Patients not reached were 1.32 times more likely to be readmitted than patients reached by centralized DPCs.

Conclusions: Centralizing the DPC program within a call center helps reach more patients and reduce readmission rates further compared with noncentralized DPCs.
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http://dx.doi.org/10.1097/JHQ.0000000000000063DOI Listing
February 2018