Publications by authors named "Sally C Stearns"

116 Publications

Coronary revascularization outcomes in relation to skilled nursing facility use following hospital discharge.

Clin Cardiol 2021 May 23;44(5):627-635. Epub 2021 Mar 23.

Division of Cardiology, UNC School of Medicine, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA.

Background: Observational analyses comparing coronary artery bypass surgery (CABG) and percutaneous coronary intervention (PCI) among elderly or frail patients are likely biased by treatment selection. PCI is typically chosen for frail patients, while CABG is more common for patients with good recovery potential.

Hypothesis: We hypothesized that skilled nursing facility (SNF) use after revascularization is a measure of relative frailty associated with outcomes following coronary revascularization.

Methods: We used a 20 percent sample of Medicare beneficiaries aged 65 years or older who received inpatient PCI or CABG between 2007-2014. Key explanatory variables were the revascularization strategy and SNF use after revascularization. We used Cox regression to evaluate death and repeat revascularization within one year and logistic regression to evaluate SNF use and 30-day readmissions/death.

Results: CABG patients were 25.1 percentage points [95% confidence interval: 24.7, 25.5] more likely to use SNF following revascularization than inpatient PCI patients. SNF use was associated with a higher death rate (hazard ratio (HR): 3.19 [3.02, 3.37]) and a 16.2 percentage point (15.5, 16.9) increase in 30-day readmissions/death. Among patients with SNF use, CABG was associated with a decrease in 30-day readmissions/death compared to PCI.

Conclusions: While CABG was associated with higher rates of SNF use and 30-day readmission/death overall, CABG was associated with significantly lower rates of 30-day readmissions/death among patients with SNF use. The findings suggest that caution is needed in treatment selection for patients at high-risk for SNF use and that selection of inpatient PCI over CABG may be associated with frailty and worse outcomes for some patients.
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http://dx.doi.org/10.1002/clc.23583DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8119835PMC
May 2021

Impact of California's mandate for antimicrobial stewardship programs on rates of methicillin-resistant and infection in acute-care hospitals.

Infect Control Hosp Epidemiol 2021 03 1;42(3):298-304. Epub 2020 Oct 1.

Department of Health Policy & Management, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, North Carolina.

Objective: To estimate the impact of California's antimicrobial stewardship program (ASP) mandate on methicillin-resistant Staphylococcus aureus (MRSA) and Clostridioides difficile infection (CDI) rates in acute-care hospitals.

Population: Centers for Medicare and Medicaid Services (CMS)-certified acute-care hospitals in the United States.

Data Sources: 2013-2017 data from the CMS Hospital Compare, Provider of Service File and Medicare Cost Reports.

Methods: Difference-in-difference model with hospital fixed effects to compare California with all other states before and after the ASP mandate. We considered were standardized infection ratios (SIRs) for MRSA and CDI as the outcomes. We analyzed the following time-variant covariates: medical school affiliation, bed count, quality accreditation, number of changes in ownership, compliance with CMS requirements, % intensive care unit beds, average length of stay, patient safety index, and 30-day readmission rate.

Results: In 2013, California hospitals had an average MRSA SIR of 0.79 versus 0.94 in other states, and an average CDI SIR of 1.01 versus 0.77 in other states. California hospitals had increases (P < .05) of 23%, 30%, and 20% in their MRSA SIRs in 2015, 2016, and 2017, respectively. California hospitals were associated with a 20% (P < .001) decrease in the CDI SIR only in 2017.

Conclusions: The mandate was associated with a decrease in CDI SIR and an increase in MRSA SIR.
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http://dx.doi.org/10.1017/ice.2020.446DOI Listing
March 2021

Insurance instability and use of emergency and office-based care after gaining coverage: An observational cohort study.

PLoS One 2020 4;15(9):e0238100. Epub 2020 Sep 4.

Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States of America.

Background: The Affordable Care Act led to improvements in reporting a usual source of care, but it is unclear whether patients are changing their usual source of care in response to coverage gains. We assess whether prior insurance instability is associated with changes in use of emergency and office-based care after the Marketplace and Medicaid expansion were introduced.

Methods: Our study draws from the 2013-14 Medical Expenditure Panel Survey, identifying a cohort of non-elderly adults with full-year health insurance coverage in 2014. We use linear and multinomial logistic regression to assess the relationship between insurance instability prior to 2014 (uninsured for 1-11 months, ≥12 months) and person-level changes in use of health care after gaining coverage (change in ED and office visits from 2013 to 2014) with continuously insured individuals serving as a comparison group.

Results: Being uninsured for at least one year prior to gaining full-year coverage in 2014 was associated with a 33% increase in ED visits (0.06 visits, p<0.01) and a 47% increase in office visits (1.10 visits, p<0.01), driven by those gaining public coverage. We found no evidence of substitution across settings in the short term, often a stated goal of expansion.

Conclusion: The long-term uninsured may have substantial health needs and pent-up demand for health care, seeing more physicians across multiple settings in the year after gaining coverage as they seek to get unmanaged conditions under control. Closing the gap in primary care use between the previously uninsured and those with health insurance coverage may help improve long-term health outcomes.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0238100PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7473517PMC
October 2020

Are Rates of Methicillin-Resistant Staphylococcus aureus and Clostridioides difficile Associated With Quality and Clinical Outcomes in US Acute Care Hospitals?

Am J Med Qual 2021 Mar-Apr 01;36(2):90-98

University of North Carolina, Chapel Hill, NC North Carolina Department of Health and Human Services, Raleigh, NC.

The purpose of this study was to examine the association between rates of methicillin-resistant Staphylococcus aureus (MRSA)/Clostridioides difficile and quality and clinical outcomes in US acute care hospitals. The population was all Medicare-certified US acute care hospitals with MRSA/C difficile standardized infection ratio (SIR) data available from 2013 to 2017. Hospital-level data from the Centers for Medicare & Medicaid Services were used to estimate hospital and time fixed effects models for 30-day hospital readmissions, length of stay, 30-day mortality, and days in the intensive care unit. The key explanatory variables were SIR for MRSA and C difficile. No association was found between MRSA or C difficile rates and any of the 4 outcomes. The null results add to the mixed evidence in the field, but there are likely residual confounding factors. Future research should use larger samples of patient-level data and appropriate methods to provide evidence to guide efforts to tackle antimicrobial resistance.
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http://dx.doi.org/10.1177/1062860620942310DOI Listing
July 2020

Brief educational video plus telecare to enhance recovery for older emergency department patients with acute musculoskeletal pain: study protocol for the BETTER randomized controlled trial.

Trials 2020 Jul 6;21(1):615. Epub 2020 Jul 6.

Department of Psychology and Neuroscience, Duke University, Durham, NC, USA.

Background: Chronic musculoskeletal pain (MSP) affects more than 40% of adults aged 50 years and older and is the leading cause of disability in the USA. Older adults with chronic MSP are at risk for analgesic-related side effects, long-term opioid use, and functional decline. Recognizing the burden of chronic MSP, reducing the transition from acute to chronic pain is a public health priority. In this paper, we report the protocol for the Brief EducaTional Tool to Enhance Recovery (BETTER) trial. This trial compares two versions of an intervention to usual care for preventing the transition from acute to chronic MSP among older adults in the emergency department (ED).

Methods: Three hundred sixty patients from the ED will be randomized to one of three arms: full intervention (an interactive educational video about pain medications and recovery-promoting behaviors, a telecare phone call from a nurse 48 to 72 h after discharge from the ED, and an electronic communication containing clinical information to the patient's primary care provider); video-only intervention (the interactive educational video but no telecare or primary care provider communication); or usual care. Data collection will occur at baseline and at 1 week and 1, 3, 6, and 12 months after study enrollment. The primary outcome is a composite measure of pain severity and interference. Secondary outcomes include physical function, overall health, opioid use, healthcare utilization, and an assessment of the economic value of the intervention.

Discussion: This trial is the first patient-facing ED-based intervention aimed at helping older adults to better manage their MSP and reduce their risk of developing chronic pain. If effective, future studies will examine the effectiveness of implementation strategies.

Trial Registration: ClinicalTrials.gov NCT04118595 . Registered on 8 October 2019.
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http://dx.doi.org/10.1186/s13063-020-04552-3DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7336469PMC
July 2020

Effectiveness of a Mouth Care Program Provided by Nursing Home Staff vs Standard Care on Reducing Pneumonia Incidence: A Cluster Randomized Trial.

JAMA Netw Open 2020 06 1;3(6):e204321. Epub 2020 Jun 1.

Gillings School of Global Public Health, University of North Carolina at Chapel Hill.

Importance: Pneumonia affects more than 250 000 nursing home (NH) residents annually. A strategy to reduce pneumonia is to provide daily mouth care, especially to residents with dementia.

Objective: To evaluate the effectiveness of Mouth Care Without a Battle, a program that increases staff knowledge and attitudes regarding oral hygiene, changes mouth care, and improves oral hygiene, in reducing the incidence of pneumonia among NH residents.

Design, Setting, And Participants: This pragmatic cluster randomized trial observing 2152 NH residents for up to 2 years was conducted from September 2014 to May 2017. Data collectors were masked to study group. The study included 14 NHs from regions of North Carolina that evidenced proportionately high rehospitalization rates for pneumonia and long-term care residents. Nursing homes were pair matched and randomly assigned to intervention or control groups.

Intervention: Mouth Care Without a Battle is a standardized program that teaches that mouth care is health care, provides instruction on individualized techniques and products for mouth care, and trains caregivers to provide care to residents who are resistant and in special situations. The control condition was standard mouth care.

Main Outcomes And Measures: Pneumonia incidence (primary) and hospitalization and mortality (secondary), obtained from medical records.

Results: Overall, the study enrolled 2152 residents (mean [SD] age, 79.4 [12.4] years; 1281 [66.2%] women; 1180 [62.2%] white residents). Participants included 1219 residents (56.6%) in 7 intervention NHs and 933 residents (43.4%) in 7 control NHs. During the 2-year study period, the incidence rate of pneumonia per 1000 resident-days was 0.67 and 0.72 in the intervention and control NHs, respectively. Neither the primary (unadjusted) nor secondary (covariate-adjusted) analyses found a significant reduction in pneumonia due to Mouth Care Without a Battle during 2 years (unadjusted incidence rate ratio, 0.90; upper bound of 1-sided 95% CI, 1.24; P = .27; adjusted incidence rate ratio, 0.92; upper bound of 1-sided 95% CI, 1.27; P = .30). In the second year, the rate of pneumonia was nonsignificantly higher in intervention NHs. Adjusted post hoc analyses limited to the first year found a significant reduction in pneumonia incidence in intervention NHs (IRR, 0.69; upper bound of 1-sided 95% CI, 0.94; P = .03).

Conclusions And Relevance: This matched-pairs cluster randomized trial of a mouth care program compared with standard care was not effective in reducing pneumonia incidence at 2 years, although reduction was found during the first year. The lack of significant results in the second year may be associated with sustainability. Improving mouth care in US NHs may require the presence and support of dedicated oral care aides.

Trial Registration: ClinicalTrials.gov Identifier: NCT03817450.
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http://dx.doi.org/10.1001/jamanetworkopen.2020.4321DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7305523PMC
June 2020

Treatment selection and medication adherence for stable angina: The role of area-based health literacy.

J Eval Clin Pract 2020 Dec 28;26(6):1711-1721. Epub 2020 Jan 28.

Department of Health Policy & Management, Gillings School of Global Public Health, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina.

Rationale, Aims, And Objectives: Clinical studies show equivalent health outcomes from interventional procedures and treatment with medication only for stable angina patients. However, patients may be subject to overuse or access barriers for interventional procedures and may exhibit suboptimal adherence to medications. Our objective is to evaluate whether community-level health literacy is associated with treatment selection and medication adherence patterns.

Method: The sample included Medicare fee-for-service beneficiaries (20% random sample) with stable angina in 2007-2013. We used an area-level health literacy variable because of the lack of an individual measure in claims. We measured the association between (a) area-based health literacy with treatment selection (medication only, percutaneous coronary intervention [PCI], or coronary artery bypass grafting (CABG) surgery) and (b) area-based health literacy with medication adherence. We controlled for other factors including demographics, co-morbidity burden, dual eligibility, and area deprivation index.

Results: We identified 8300 patients of whom 8.7% lived in a low health literacy area. Overall, 56% of patients received medication only, 28% received PCI, and 15% received CABG. Patients in low health literacy areas were less likely to receive CABG (-3.5 percentage points; 95% CI, -6.8 to -0.3) than were patients in high health literacy areas, but the significance was sensitive to specification. Overall, 81.5% and 71.5% of patients were adherent to antianginals and statins, respectively. Living in low health literacy areas was associated with lower adherence to antianginals (-3.3 percentage points; 95% CI, -6.1 to -0.6) but not statins.

Conclusions: Low area-based health literacy was associated with being less likely to receive CABG and lower adherence, but the differences between low and high health literacy areas were small and sensitive to model specification. Individual factors such as dual eligibility status and race/ethnicity had stronger associations with outcomes than had area-based health literacy, suggesting that this area-based measure was inadequate to account for social determinants in this study.
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http://dx.doi.org/10.1111/jep.13341DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7552995PMC
December 2020

Post-Acute Care Locations: Hospital Discharge Destination Reports vs Medicare Claims.

J Am Geriatr Soc 2020 04 27;68(4):847-851. Epub 2019 Dec 27.

Department of Health Policy and Management, The University of North Carolina at Chapel Hill, Gillings School of Global Public Health, Chapel Hill, North Carolina.

Objectives: Administrative records such as Medicare fee-for-service (FFS) claims provide accurate information on services paid for by Medicare. However, the increasing availability of electronic health records means many researchers may be inclined to rely on data coded in hospital information systems rather than claims. The current quality and accuracy of hospital reports on the use of post-acute care (PAC) services are not known.

Design: This study examined differences in the PAC use between hospital discharge status recorded on Medicare Provider and Analysis Review inpatient hospital records and claims for PAC services.

Setting: In addition to assessments of the three types of Medicare-reimbursed PAC (home health agency [HHA], skilled nursing facility [SNF], and inpatient rehabilitation facility [IRF]), the analysis also considered home without PAC services as a default discharge location.

Participants: The analysis was conducted using data for FFS beneficiaries who participated in the Medicare Current Beneficiary Survey and had one or more inpatient hospitalizations from 2006 to 2011.

Measurements: This study measured discrepancies between hospital-reported discharges to PAC and PAC use based on Medicare claims.

Results: The study found that, on average, 27.9% of hospital reports of discharging to Medicare-covered PAC services were not substantiated by Medicare PAC claims. Among all the discharge pathways, discharging to HHAs had the highest discrepancy rate (29.6%), followed by IRFs (14.7%) and SNFs (13.8%).

Conclusion: The study results call for cautions about the extent to which the reported discharge locations on hospital claims may differ from actual PAC services used. Assuming that Medicare FFS claims were complete and accurate, researchers using the discharge status reported on Medicare hospital claims should be aware of possible measurement errors when using hospital-reported discharge locations. J Am Geriatr Soc 68:847-851, 2020.
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http://dx.doi.org/10.1111/jgs.16308DOI Listing
April 2020

Association between statewide adoption of the CDC's Core Elements of Hospital Antimicrobial Stewardship Programs and rates of methicillin-resistant bacteremia and infection in the United States.

Infect Control Hosp Epidemiol 2020 04 20;41(4):430-437. Epub 2019 Dec 20.

Department of Health Policy & Management, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, North Carolina.

Objective: To measure the association between statewide adoption of the Centers for Disease Control and Prevention's (CDC's) Core Elements for Hospital Antimicrobial Stewardship Programs (Core Elements) and hospital-associated methicillin-resistant Staphylococcus aureus bacteremia (MRSA) and Clostridioides difficile infection (CDI) rates in the United States. We hypothesized that states with a higher percentage of reported compliance with the Core Elements have significantly lower MRSA and CDI rates.

Participants: All US states.

Design: Observational longitudinal study.

Methods: We used 2014-2016 data from Hospital Compare, Provider of Service files, Medicare cost reports, and the CDC's Patient Safety Atlas website. Outcomes were MRSA standardized infection ratio (SIR) and CDI SIR. The key explanatory variable was the percentage of hospitals that meet the Core Elements in each state. We estimated state and time fixed-effects models with time-variant controls, and we weighted our analyses for the number of hospitals in the state.

Results: The percentage of hospitals reporting compliance with the Core Elements between 2014 and 2016 increased in all states. A 1% increase in reported ASP compliance was associated with a 0.3% decrease (P < .01) in CDIs in 2016 relative to 2014. We did not find an association for MRSA infections.

Conclusions: Increasing documentation of the Core Elements may be associated with decreases in the CDI SIR. We did not find evidence of such an association for the MRSA SIR, probably due to the short length of the study and variety of stewardship strategies that ASPs may encompass.
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http://dx.doi.org/10.1017/ice.2019.352DOI Listing
April 2020

The Medicare Shared Savings Program and Outcomes for Ischemic Stroke Patients: a Retrospective Cohort Study.

J Gen Intern Med 2019 12 26;34(12):2740-2748. Epub 2019 Aug 26.

Duke Clinical Research Institute, Durham, NC, USA.

Background: Post-stroke care delivery may be affected by provider participation in Medicare Shared Savings Program (MSSP) Accountable Care Organizations (ACOs) through systematic changes to discharge planning, care coordination, and transitional care.

Objective: To evaluate the association of MSSP with patient outcomes in the year following hospitalization for ischemic stroke.

Design: Retrospective cohort SETTING: Get With The Guidelines (GWTG)-Stroke (2010-2014) PARTICIPANTS: Hospitalizations for mild to moderate incident ischemic stroke were linked with Medicare claims for fee-for-service beneficiaries ≥ 65 years (N = 251,605).

Main Measures: Outcomes included discharge to home, 30-day all-cause readmission, length of index hospital stay, days in the community (home-time) at 1 year, and 1-year recurrent stroke and mortality. A difference-in-differences design was used to compare outcomes before and after hospital MSSP implementation for patients (1) discharged from hospitals that chose to participate versus not participate in MSSP or (2) assigned to an MSSP ACO versus not or both. Unique estimates for 2013 and 2014 ACOs were generated.

Key Results: For hospitals joining MSSP in 2013 or 2014, the probability of discharge to home decreased by 2.57 (95% confidence intervals (CI) = - 4.43, - 0.71) percentage points (pp) and 1.84 pp (CI = - 3.31, - 0.37), respectively, among beneficiaries not assigned to an MSSP ACO. Among discharges from hospitals joining MSSP in 2013, beneficiary ACO alignment versus not was associated with increased home discharge, reduced length of stay, and increased home-time. For patients discharged from hospitals joining MSSP in 2014, ACO alignment was not associated with changes in utilization. No association between MSSP and recurrent stroke or mortality was observed.

Conclusions: Among patients with mild to moderate ischemic stroke, meaningful reductions in acute care utilization were observed only for ACO-aligned beneficiaries who were also discharged from a hospital initiating MSSP in 2013. Only 1 year of data was available for the 2014 MSSP cohort, and these early results suggest further study is warranted.

Registration: None.
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http://dx.doi.org/10.1007/s11606-019-05283-1DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6854149PMC
December 2019

Patient-Clinician Decision Making for Stable Angina: The Role of Health Literacy.

EGEMS (Wash DC) 2019 Aug 9;7(1):42. Epub 2019 Aug 9.

Mayo Clinic, US.

Background: Stable angina patients have difficulty understanding the tradeoffs between treatment alternatives. In this analysis, we assessed treatment planning conversations for stable angina to determine whether inadequate health literacy acts as a barrier to communication that may partially explain this difficulty.

Methods: We conducted a descriptive analysis of patient questionnaire data from the PCI Choice Trial. The main outcomes were the responses to the Decisional Conflict Scale and the proportion of correct responses to knowledge questions about stable angina. We also conducted a qualitative analysis on recordings of patient-clinician discussions about treatment planning. The recordings were coded with the OPTION12 instrument for shared decision-making. Two analysts independently assessed the number and types of patient questions and expressions of preferences.

Results: Patient engagement did not differ by health literacy level and was generally low for all patients with respect to OPTION12 scores and the number of questions related to clinical aspects of treatment. Patients with inadequate health literacy had significantly higher decisional conflict. However, the proportion of knowledge questions answered correctly did not differ significantly by health literacy level.

Conclusions: Patients with inadequate health literacy had greater decisional conflict but no difference in knowledge compared to patients with adequate health literacy. Inadequate health literacy may act as a barrier to communication, but gaps were found in patient engagement and knowledge for patients of all health literacy levels. The recorded patient-clinician encounters and the health literacy measure were valuable resources for conducting research on care delivery.
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http://dx.doi.org/10.5334/egems.306DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6688543PMC
August 2019

Medicare Shared Savings ACOs and Hospice Care for Ischemic Stroke Patients.

J Am Geriatr Soc 2019 07 5;67(7):1402-1409. Epub 2019 Mar 5.

Duke Sanford School of Public Policy, Durham, North Carolina.

Objectives: Palliative care services have the potential to improve the quality of end-of-life care and reduce cost. Services such as the Medicare hospice benefit, however, are often underutilized among stroke patients with a poor prognosis. We tested the hypothesis that the Medicare Shared Savings Program (MSSP) is associated with increased hospice enrollment and inpatient comfort measures only among incident ischemic stroke patients with a high mortality risk.

Design: A difference-in-differences design was used to compare outcomes before and after hospital participation in the MSSP for patients discharged from MSSP hospitals (N = 273) vs non-MSSP hospitals (N = 1490).

Setting: Records from a national registry, Get with the Guidelines (GWTG)-Stroke, were linked to Medicare hospice claims (2010-2015).

Participants: Fee-for-service Medicare beneficiaries age 65 and older hospitalized for incident ischemic stroke at a GWTG-Stroke hospital from January 2010 to December 2014 (N = 324 959).

Intervention: Discharge from an MSSP hospital or beneficiary alignment with an MSSP Accountable Care Organization (ACO).

Measurements: Hospice enrollment in the year following stroke.

Results: Among patients with high mortality risk, ACO alignment was associated with a 16% increase in odds of hospice enrollment (adjusted odds ratio [OR] = 1.16; 95% confidence interval [CI] = 1.06-1.26), increasing the probability of hospice enrollment from 20% to 22%. In the low mortality risk group, discharge from an MSSP vs non-MSSP hospital was associated with a decrease in the predicted probability of inpatient comfort measures or discharge to hospice from 9% to 8% (OR = .82; CI = .74-.91), and ACO alignment was associated with reduced odds of a short stay (<7 days) (OR = .86; CI = .77-.96).

Conclusion: Among ischemic stroke patients with severe stroke or indicators of high mortality risk, MSSP was associated with increased hospice enrollment. MSSP contract incentives may motivate improved end-of-life care among the subgroups most likely to benefit.
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http://dx.doi.org/10.1111/jgs.15852DOI Listing
July 2019

Improving Nursing Home Residents' Oral Hygiene: Results of a Cluster Randomized Intervention Trial.

J Am Med Dir Assoc 2018 12;19(12):1086-1091

Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC.

Objective: A 2-year cluster randomized trial of Mouth Care Without a Battle (MCWB) was conducted in nursing homes (NHs) to determine if recommended mouth care practices provided by NH staff could improve residents' oral hygiene and denture outcomes.

Design: Cluster randomized trial of NHs.

Setting And Participants: Seven MCWB NHs and 6 control NHs. A total of 219 NH residents completed baseline and 24-month oral examinations and, if applicable, denture assessments (control = 98, intervention = 121).

Intervention: The intervention consisted of training NH staff in the MCWB protocol, and providing support in its use for 2 years.

Measures: Descriptive data from the Minimum Data Set and clinical oral health assessments: the Plaque Index for Long-Term Care (range 0‒3), the Gingival Index for Long-Term Care (range 0‒4), and the Denture Plaque Index (range 0‒4), with lower scores indicating better oral health.

Results: There were no significant demographic or health differences between groups at baseline. Residents' mean age (standard deviation) was 77.8 years (13.5), 71% were female, and 49% had cognitive impairment. At 24 months, there were significant improvements in oral and denture hygiene in the intervention group compared with control (all P < .05) with mean changes in indices that were 0.44 (Plaque Index for Long-Term Care), 0.55 (Gingival Index for Long-Term Care), and 0.67 (Denture Plaque Index) points lower in intervention NHs than control NHs.

Conclusions And Implications For Practice: Training NH staff to attend to residents' oral hygiene and denture care had a sustained, favorable impact on residents' oral and denture hygiene after 24 months compared with usual care. The protocol, MCWB, can be used by direct caregivers to improve the oral hygiene and denture care of NH residents.
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http://dx.doi.org/10.1016/j.jamda.2018.09.036DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6396648PMC
December 2018

Heart Failure and Cognitive Impairment in the Atherosclerosis Risk in Communities (ARIC) Study.

J Gen Intern Med 2018 10 20;33(10):1721-1728. Epub 2018 Jul 20.

Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.

Background: Previous studies suggest that heart failure (HF) is an independent risk factor for cognitive decline. A better understanding of the relationship between HF, cognitive status, and cognitive decline in a community-based sample may help clinicians understand disease risk.

Objective: To examine whether persons with HF have a higher prevalence of cognitive impairment and whether persons developing HF have more rapid cognitive decline.

Design: This observational cohort study of American adults in the Atherosclerosis Risk in Communities (ARIC) study has two components: cross-sectional analysis examining the association between prevalent HF and cognition using multinomial logistic regression, and change over time analysis detailing the association between incident HF and change in cognition over 15 years.

Participants: Among visit 5 (2011-2013) participants (median age 75 years), 6495 had neurocognitive information available for cross-sectional analysis. Change over time analysis examined the 5414 participants who had cognitive scores and no prevalent HF at visit 4 (1996-1998).

Measurements: The primary outcome was cognitive status, classified as normal, mild cognitive impairment [MCI], and dementia on the basis of standardized cognitive tests (delayed word recall, word fluency, and digit symbol substitution). Cognitive change was examined over a 15-year period. Control variables included socio-demographic, vascular, and smoking/drinking measures.

Results: At visit 5, participants with HF had a higher prevalence of dementia (adjusted relative risk ratio [RRR] = 1.60 [95% CI 1.13, 2.25]) and MCI (RRR = 1.36 [1.12, 1.64]) than those without HF. A decline in cognition between visits 4 and 5 was - 0.07 standard deviation units [- 0.13, - 0.01] greater among persons who developed HF compared to those who did not. Results did not differ by ejection fraction.

Conclusion: HF is associated with neurocognitive dysfunction and decline independent of other co-morbid conditions. Further study is needed to determine the underlying pathophysiology.
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http://dx.doi.org/10.1007/s11606-018-4556-xDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6153245PMC
October 2018

Recurrent Acute Decompensated Heart Failure Admissions for Patients With Reduced Versus Preserved Ejection Fraction (from the Atherosclerosis Risk in Communities Study).

Am J Cardiol 2018 07 28;122(1):108-114. Epub 2018 Mar 28.

Department of Medicine, Division of Cardiology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina.

Hospitals are required to report all-cause 30-day readmissions for patients discharged with heart failure. Same-cause readmissions have received less attention but may differ for heart failure with reduced ejection fraction (HFrEF) versus heart failure with preserved ejection fraction (HFpEF). The ARIC study began abstracting medical records for cohort members hospitalized with acute decompensated heart failure (ADHF) in 2005. ADHF was validated by physician review, with HFrEF defined by ejection fraction <50%. Recurrent admissions for ADHF were analyzed within 30 days, 90 days, 6 months, and 1 year of the index hospitalization using repeat-measures Cox regression models. All recurrent ADHF admissions per patient were counted rather than the more typical analysis of only the first occurring readmission. From 2005 to 2014, 1,133 cohort members survived at least 1 hospitalization for ADHF and had ejection fraction recorded. Half were classified as HFpEF. Patients with HFpEF were more often women and had more co-morbidities. The overall ADHF readmission rate was greatest within 30 days of discharge but was higher for patients with HFrEF (115 vs 88 readmissions per 100 person-years). After adjustments for demographics, year of admission, and co-morbidities, there was a trend for higher ADHF readmissions with HFrEF, relative to HFpEF, at 30 days (hazard ratio [HR] 1.41, 95% confidence interval [CI] 0.92 to 2.18), 90 days (HR 1.39, 95% CI 1.05 to 1.85), 6 months (HR 1.47, 95% CI, 1.18 to 1.84), and 1 year (HR 1.42, 95% CI 1.18 to 1.70) of follow-up. In conclusion, patients with HFrEF have a greater burden of short- and long-term readmissions for recurrent ADHF.
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http://dx.doi.org/10.1016/j.amjcard.2018.03.011DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6842896PMC
July 2018

Costs at the End of Life: Perspectives for North Carolina.

N C Med J 2018 Jan-Feb;79(1):43-45

professor, Department of Health Policy and Management, Gillings School of Global Public Health; senior researcher, Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina

Many elders require supportive services, with many costs covered by Medicaid. Once terminal illness sets in, palliative care and hospice may help control cost while ensuring quality. This commentary reviews trends in cost at the end of life and describes selected strategies to improve patient-centered care in North Carolina.
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http://dx.doi.org/10.18043/ncm.79.1.43DOI Listing
June 2018

Guideline-Directed Medical Therapy and Survival Following Hospitalization in Patients with Heart Failure.

Pharmacotherapy 2018 04 22;38(4):406-416. Epub 2018 Mar 22.

UNC Eshelman School of Pharmacy, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina.

Background: Modification of guideline-directed medical therapy (GDMT) in hospitalized patients with heart failure (HF) has not been extensively evaluated.

Methods: The community surveillance arm of the Atherosclerosis Risk in Communities Study identified 6959 HF hospitalizations from 2005-2011. Predictors of GDMT modification and survival were assessed using multivariable logistic regression and Cox proportional hazards models.

Results: For 5091 hospitalizations, patient mean age was 75 years, 53% were female, 69% were white, and 81% had acute decompensated heart failure (ADHF). Regarding ejection fraction (EF), 31% of patients had HF with reduced EF (HFrEF), 24% had HF with preserved EF (HFpEF), and 44% were missing EF values. At admission, 52% of patients received angiotensin-converting enzyme inhibitors/angiotensin receptor blockers (ACEIs/ARBs), 66% β-blockers (BBs), 9% aldosterone-receptor antagonists, 16% digoxin, 10% hydralazine, and 29% nitrates. Modification of GDMT occurred in up to 23% of hospitalizations. Significant predictors of GDMT initiation included ADHF and HFrEF; discontinuation of medications was observed with select comorbidities. In HFrEF, initiation of any GDMT was associated with reduced 1-year all-cause mortality (adjusted hazard ratio [HR] 0.41, 95% confidence interval [CI] 0.23-0.71) as was initiation of ACEI/ARBs, BBs, and digoxin. Discontinuation of any therapy versus maintaining GDMT was associated with greater mortality (HR 1.30, 95% CI 1.02-1.66). Similar trends were observed in HFpEF.

Conclusions: Our study suggests that GDMT initiation is associated with increased survival, and discontinuation of therapy is associated with reduced survival in hospitalized patients with HF. Future studies should be conducted to confirm the impact of GDMT therapy modification in this population.
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http://dx.doi.org/10.1002/phar.2091DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5902433PMC
April 2018

Position matters: Validation of medicare hospital claims for myocardial infarction against medical record review in the atherosclerosis risk in communities study.

Pharmacoepidemiol Drug Saf 2018 10 6;27(10):1085-1091. Epub 2018 Feb 6.

University of North Carolina, Chapel Hill, NC, USA.

Purpose: The objectives of this study were to investigate sensitivity and specificity of myocardial infarction (MI) case definitions using multiple discharge code positions and multiple diagnosis codes when comparing administrative data to hospital surveillance data.

Methods: Hospital surveillance data for ARIC Study cohort participants with matching participant ID and service dates to Centers for Medicare and Medicaid Services (CMS) hospitalization records for hospitalizations occurring between 2001 and 2013 were included in this study. Classification of Definite or Probable MI from ARIC medical record review defined "gold standard" comparison for validation measures. In primary analyses, an MI was defined with ICD9 code 410 from CMS records. Secondary analyses defined MI using code 410 in combination with additional codes.

Results: A total of 25 549 hospitalization records met study criteria. In primary analysis, specificity was at least 0.98 for all CMS definitions by discharge code position. Sensitivity ranged from 0.48 for primary position only to 0.63 when definition included any discharge code position. The sensitivity of definitions including codes 410 and 411.1 were higher than sensitivity observed when using code 410 alone. Specificity of these alternate definitions was higher for women (0.98) than for men (0.96).

Conclusion: Algorithms that rely exclusively on primary discharge code position will miss approximately 50% of all MI cases due to low sensitivity of this definition. We recommend defining MI by code 410 in any of first 5 discharge code positions overall and by codes 410 and 411.1 in any of first 3 positions for sensitivity analyses of women.
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http://dx.doi.org/10.1002/pds.4396DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6233317PMC
October 2018

Novel Care Pathway for Patients Presenting to the Emergency Department With Atrial Fibrillation.

Circ Cardiovasc Qual Outcomes 2018 01;11(1):e004129

From the Division of Cardiology, Department of Medicine (A.G., P.M., T.J.W., S.C., J.O., K.G.), University of North Carolina Medical Center (Z.D., L.H.), Division of Practice Advancement and Clinical Education, University of North Carolina Eshelman School of Pharmacy (Z.D., P.M., L.H.), Gillings School of Global Public Health (J.L., J.A., S.S.), and Department of Emergency Medicine (K.B.), University of North Carolina at Chapel Hill; and Department of Psychology (S.S.), Department of Cardiovascular Sciences (S.S.), and Department of Public Health (S.S.), East Carolina University, Greenville, NC.

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http://dx.doi.org/10.1161/CIRCOUTCOMES.117.004129DOI Listing
January 2018

Telephone Follow-Up for Older Adults Discharged to Home from the Emergency Department: A Pragmatic Randomized Controlled Trial.

J Am Geriatr Soc 2018 03 22;66(3):452-458. Epub 2017 Dec 22.

Center for Aging and Health, Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina.

Background/objectives: Telephone calls after discharge from the emergency department (ED) are increasingly used to reduce 30-day rates of return or readmission, but their effectiveness is not established. The objective was to determine whether a scripted telephone intervention by registered nurses from a hospital-based call center would decrease 30-day rates of return to the ED or hospital or of death.

Design: Randomized, controlled trial from 2013 to 2016.

Setting: Large, academic medical center in the southeast United States.

Participants: Individuals aged 65 and older discharged from the ED were enrolled and randomized into intervention and control groups (N = 2,000).

Intervention: Intervention included a telephone call from a nurse using a scripted questionnaire to identify obstacles to elements of successful care transitions: medication acquisition, postdischarge instructions, and obtaining physician follow-up. Control subjects received a satisfaction survey only.

Measurements: Primary outcome was return to the ED, hospitalization, or death within 30 days of discharge from the ED.

Results: Rate of return to the ED or hospital or death within 30 days was 15.5% (95% confidence interval (CI) = 13.2-17.8%) in the intervention group and 15.2% (95% CI = 12.9-17.5%) in the control group (P = .86). Death was uncommon (intervention group, 0; control group, 5 (0.51%), 95% CI = 0.06-0.96%); 12.2% of intervention subjects (95% CI = 10.1-14.3%) and 12.5% of control subjects (95% CI = 10.4-14.6%) returned to the ED, and 9% of intervention subjects (95% CI = 7.2-10.8%) and 7.4% of control subjects (95% CI = 5.8-9.0%) were hospitalized within 30 days.

Conclusion: A scripted telephone call from a trained nurse to an older adult after discharge from the ED did not reduce ED or hospital return rates or death within 30 days. Clinicaltrials.gov identifier: NCT01893931z.
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http://dx.doi.org/10.1111/jgs.15142DOI Listing
March 2018

Impact of Accountable Care Organizations on Utilization, Care, and Outcomes: A Systematic Review.

Med Care Res Rev 2019 06 12;76(3):255-290. Epub 2017 Dec 12.

2 Duke Clinical Research Institute, Durham, NC, USA.

Since 2010, more than 900 accountable care organizations (ACOs) have formed payment contracts with public and private insurers in the United States; however, there has not been a systematic evaluation of the evidence studying impacts of ACOs on care and outcomes across payer types. This review evaluates the quality of evidence regarding the association of public and private ACOs with health service use, processes, and outcomes of care. The 42 articles identified studied ACO contracts with Medicare ( N = 24 articles), Medicaid ( N = 5), commercial ( N = 11), and all payers ( N = 2). The most consistent associations between ACO implementation and outcomes across payer types were reduced inpatient use, reduced emergency department visits, and improved measures of preventive care and chronic disease management. The seven studies evaluating patient experience or clinical outcomes of care showed no evidence that ACOs worsen outcomes of care; however, the impact on patient care and outcomes should continue to be monitored.
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http://dx.doi.org/10.1177/1077558717745916DOI Listing
June 2019

Do Live Discharge Rates Increase as Hospices Approach Their Medicare Aggregate Payment Caps?

J Pain Symptom Manage 2018 03 26;55(3):775-784. Epub 2017 Nov 26.

Department of Health Policy and Management, Gillings School of Global Public Health, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina.

Context: The rate of live discharge from hospice and the proportion of hospices exceeding their aggregate caps have both increased for the last 15 years, becoming a source of federal scrutiny. The cap restricts aggregate payments hospices receive from Medicare during a 12-month period. The risk of repayment and the manner in which the cap is calculated may incentivize hospices coming close to their cap ceilings to discharge existing patients before the end of the cap year.

Objective: The objective of this work was to explore annual cap-risk trends and live discharge patterns. We hypothesized that as a hospice comes closer to exceeding its cap, a patient's likelihood of being discharged alive increases.

Methods: We analyzed monthly hospice outcomes using 2012-2013 Medicare claims.

Results: Adjusted analyses showed a positive and statistically significant relationship between cap risk and live discharges.

Conclusion: Policymakers ought to consider the unintended consequences the aggregate cap may be having on patient outcomes of care.
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http://dx.doi.org/10.1016/j.jpainsymman.2017.11.018DOI Listing
March 2018

Predictors of Medication Adherence in the Elderly: The Role of Mental Health.

Med Care Res Rev 2018 12 23;75(6):746-761. Epub 2017 Mar 23.

2 Gillings School of Global Public Health, The University of North Carolina at Chapel Hill, NC, USA.

The aging population routinely has comorbid conditions requiring complicated medication regimens, yet nonadherence can preclude optimal outcomes. This study explored the association of adherence in the elderly with demographic, socioeconomic, and disease burden measures. Data were from the fifth visit (2011-2013) for 6,538 participants in the Atherosclerosis Risk in Communities Study, conducted in four communities. The Morisky-Green-Levine Scale measured self-reported adherence. Forty percent of respondents indicated some nonadherence, primarily due to poor memory. Logit regression showed, surprisingly, that persons with low reading ability were more likely to report being adherent. Better self-reported physical or mental health both predicted better adherence, but the magnitude of the association was greater for mental than for physical health. Compared with persons with normal or severely impaired cognition, mild cognitive impairment was associated with lower adherence. Attention to mental health measures in clinical settings could provide opportunities for improving medication adherence.
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http://dx.doi.org/10.1177/1077558717696992DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5704980PMC
December 2018

Contribution of medications and risk factors to QTc interval lengthening in the atherosclerosis risk in communities (ARIC) study.

J Eval Clin Pract 2017 Dec 10;23(6):1274-1280. Epub 2017 Jul 10.

UNC Eshelman School of Pharmacy, The University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.

Rationale, Aims, And Objectives: Prolongation of the corrected QT (QTc) interval is associated with increased morbidity and mortality. The association between QTc interval-prolonging medications (QTPMs) and risk factors with magnitude of QTc interval lengthening is unknown. We examined the contribution of risk factors alone and in combination with QTPMs to QTc interval lengthening.

Method: The Atherosclerosis Risk in Communities study assessed 15 792 participants with a resting, standard 12-lead electrocardiogram and ≥1 measure of QTc interval over 4 examinations at 3-year intervals (1987-1998). From 54 638 person-visits, we excluded participants with QRS ≥ 120 milliseconds (n = 2333 person-visits). We corrected the QT interval using the Bazett and Framingham formulas. We examined QTc lengthening using linear regression for 36 602 person-visit observations for 14 160 cohort members controlling for age ≥ 65 years, female sex, left ventricular hypertrophy, QTc > 500 milliseconds at the prior visit, and CredibleMeds categorized QTPMs (Known, Possible, or Conditional risk). We corrected standard errors for repeat observations per person.

Results: Eighty percent of person-visits had at least one risk factor for QTc lengthening. Use of QTPMs increased over the 4 visits from 8% to 17%. Among persons not using QTPMs, history of prolonged QTc interval and female sex were associated with the greatest QTc lengthening, 39 and 12 milliseconds, respectively. In the absence of risk factors, Known QTPMs and ≥2 QTPMs were associated with modest but greater QTc lengthening than Possible or Conditional QTPMs. In the presence of risk factors, ≥2 QTPM further increased QTc lengthening. In combination with risk factors, the association of all QTPM categories with QTc lengthening was greater than QTPMs alone.

Conclusion: Risk factors, particularly female sex and history of prolonged QTc interval, have stronger associations with QTc interval lengthening than any QTPM category alone. All QTPM categories augmented QTc interval lengthening associated with risk factors.
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http://dx.doi.org/10.1111/jep.12776DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5741511PMC
December 2017

A Positive Association Between Hospice Profit Margin And The Rate At Which Patients Are Discharged Before Death.

Health Aff (Millwood) 2017 07;36(7):1291-1298

Pam Silberman is a professor of the practice and director of the Executive Doctoral Program in Health Leadership, Department of Health Policy and Management, Gillings School of Global Public Health, and associate director for policy analysis at the Cecil G. Sheps Center for Health Services Research, all at UNC.

Hospice care is designed to support patients and families through the final phase of illness and death. Yet for more than a decade, hospices have steadily increased the rate at which they discharge patients before death-a practice known as "live discharge." Although certain live discharges are consistent with high-quality care, regulators have expressed concern that some hospices' desire to maximize profits drives them to inappropriately discharge patients. We used Medicare claims data for 2012-13 and cost reports for 2011-13 to explore relationships between hospice-level financial margins and live discharge rates among freestanding hospices. Adjusted analyses showed positive and significant associations between both operating and total margins and hospice-level rates of live discharge: One-unit increases in operating and total margin were associated with increases of 3 percent and 4 percent in expected hospice-level live discharge rates, respectively. These findings suggest that additional research is needed to explore links between profitability and patient-centeredness in the Medicare hospice program.
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http://dx.doi.org/10.1377/hlthaff.2017.0113DOI Listing
July 2017

The US President's Malaria Initiative and under-5 child mortality in sub-Saharan Africa: A difference-in-differences analysis.

PLoS Med 2017 Jun 13;14(6):e1002319. Epub 2017 Jun 13.

Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States of America.

Background: Despite substantial financial contributions by the United States President's Malaria Initiative (PMI) since 2006, no studies have carefully assessed how this program may have affected important population-level health outcomes. We utilized multiple publicly available data sources to evaluate the association between introduction of PMI and child mortality rates in sub-Saharan Africa (SSA).

Methods And Findings: We used difference-in-differences analyses to compare trends in the primary outcome of under-5 mortality rates and secondary outcomes reflecting population coverage of malaria interventions in 19 PMI-recipient and 13 non-recipient countries between 1995 and 2014. The analyses controlled for presence and intensity of other large funding sources, individual and household characteristics, and country and year fixed effects. PMI program implementation was associated with a significant reduction in the annual risk of under-5 child mortality (adjusted risk ratio [RR] 0.84, 95% CI 0.74-0.96). Each dollar of per-capita PMI expenditures in a country, a measure of PMI intensity, was also associated with a reduction in child mortality (RR 0.86, 95% CI 0.78-0.93). We estimated that the under-5 mortality rate in PMI countries was reduced from 28.9 to 24.3 per 1,000 person-years. Population coverage of insecticide-treated nets increased by 8.34 percentage points (95% CI 0.86-15.83) and coverage of indoor residual spraying increased by 6.63 percentage points (95% CI 0.79-12.47) after PMI implementation. Per-capita PMI spending was also associated with a modest increase in artemisinin-based combination therapy coverage (3.56 percentage point increase, 95% CI -0.07-7.19), though this association was only marginally significant (p = 0.054). Our results were robust to several sensitivity analyses. Because our study design leaves open the possibility of unmeasured confounding, we cannot definitively interpret these results as causal.

Conclusions: PMI may have significantly contributed to reducing the burden of malaria in SSA and reducing the number of child deaths in the region. Introduction of PMI was associated with increased coverage of malaria prevention technologies, which are important mechanisms through which child mortality can be reduced. To our knowledge, this study is the first to assess the association between PMI and all-cause child mortality in SSA with the use of appropriate comparison groups and adjustments for regional trends in child mortality.
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http://dx.doi.org/10.1371/journal.pmed.1002319DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5469567PMC
June 2017

Mind the Gap: Hospitalizations from Multiple Sources in a Longitudinal Study.

Value Health 2017 06 9;20(6):777-784. Epub 2016 Jun 9.

Duke Clinical Research Institute, Duke University, Durham, NC, USA.

Background: Medicare claims and prospective studies with self-reported utilization are important sources of hospitalization data for epidemiologic and outcomes research.

Objectives: To assess the concordance of Medicare claims merged with interview-based surveillance data to determine factors associated with source completeness.

Methods: The Atherosclerosis Risk in Communities (ARIC) study recruited 15,792 cohort participants aged 45 to 64 years in the period 1987 to 1989 from four communities. Hospitalization records obtained through cohort report and hospital record abstraction were matched to Medicare inpatient records (MedPAR) from 2006 to 2011. Factors associated with concordance were assessed graphically and using multinomial logit regression.

Results: Among fee-for-service enrollees, MedPAR and ARIC hospitalizations matched approximately 67% of the time. For Medicare Advantage enrollees, completeness increased after initiation of hospital financial incentives in 2008 to submit shadow bills for Medicare Advantage enrollees. Concordance varied by geographic site, age, veteran status, proximity to death, study attrition, and whether hospitalizations were within ARIC catchment areas.

Conclusions: ARIC and MedPAR records had good concordance among fee-for-service enrollees, but many hospitalizations were available from only one source. MedPAR hospital records may be missing for veterans or observation stays. Maintaining study participation increases stay completeness, but new sources such as electronic health records may be more efficient than surveillance for mobile elderly populations.
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http://dx.doi.org/10.1016/j.jval.2016.04.012DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5458617PMC
June 2017

Redistribution and redesign in health care: An ebbing tide in England versus growing concerns in the United States.

Health Econ 2017 06;26(6):687-690

Department of Health Policy and Management, The University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.

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http://dx.doi.org/10.1002/hec.3516DOI Listing
June 2017

Factors Driving Live Discharge From Hospice: Provider Perspectives.

J Pain Symptom Manage 2017 06 16;53(6):1050-1056. Epub 2017 Mar 16.

Department of Health Policy and Management, Gillings School of Global Public Health, The University of North Carolina at Chapel Hill, North Carolina, USA.

Context: The proportion of patients disenrolling from hospice before death has increased over the decade with significant variations across hospice types and regions. Such trends have raised concerns about live disenrollment's effect on care quality. Live disenrollment may be driven by factors other than patient preference and may create discontinuities in care, disrupting ongoing patient-provider relationships. Researchers have not explored when and how providers make this decision with patients.

Objective: The objective of this study was to ascertain provider perspectives on key drivers of live discharge from the Medicare hospice program.

Methods: We conducted semistructured telephone interviews with 18 individuals representing 14 hospice providers across the country. Transcriptions were coded and analyzed using a template analysis approach.

Results: Analysis generated four themes: 1) difficulty estimating patient prognosis, 2) fear of Centers for Medicare & Medicaid Services audits, 3) rising market competition, and 4) challenges with inpatient contracting. Participants emphasized challenges underlying each decision to discharge patients alive, stressing that there often exists a gray line between appropriate and inappropriate discharges. Discussions also focused on scenarios in which financial motivations drive enrollment and disenrollment practices.

Conclusion: This study provides significant contributions to existing knowledge about hospice enrollment and disenrollment patterns. Results suggest that live discharge patterns are often susceptible to market and regulatory forces, which may have contributed to the rising national rate.
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http://dx.doi.org/10.1016/j.jpainsymman.2017.02.004DOI Listing
June 2017

A Comparison of Self-reported Medication Adherence to Concordance Between Part D Claims and Medication Possession.

Med Care 2017 May;55(5):500-505

*Department of Health Policy & Management †Cecil G. Sheps Center for Health Services Research, The University of North Carolina at Chapel Hill ‡UNC Eshelman School of Pharmacy, Chapel Hill, NC §College of Pharmacy, King Saud University, Riyadh, Kingdom of Saudi Arabia.

Objective: Medicare Part D claims indicate medication purchased, but people who are not fully adherent may extend prescription use beyond the interval prescribed. This study assessed concordance between Part D claims and medication possession at a study visit in relation to self-reported medication adherence.

Materials And Methods: We matched Part D claims for 6 common medications to medications brought to a study visit in 2011-2013 for the Atherosclerosis Risk in Communities study. The combined data consisted of 3027 medication events (claims, medications possessed, or both) for 2099 Atherosclerosis Risk in Communities study participants. Multinomial logistic regression estimated the association of concordance (visit only, Part D only, or both) with self-reported medication adherence while controlling for sociodemographic characteristics, veteran status, and availability under Generic Drug Discount Programs.

Results: Relative to participants with high adherence, medication events for participants with low adherence were approximately 25 percentage points less likely to match and more likely to be visit only (P<0.001). The results were similar but smaller in magnitude (approximately 2-3 percentage points) for participants with medium adherence. Compared with females, medication events for male veterans were approximately 11 percentage points less likely to match and more likely to be visit only. Events for medications available through Generic Drug Discount Programs were 3 percentage points more likely to be visit only.

Conclusions: Part D claims were substantially less likely to be concordant with medications possessed at study visit for participants with low self-reported adherence. This result supports the construction of adherence proxies such as proportion days covered using Part D claims.
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http://dx.doi.org/10.1097/MLR.0000000000000701DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5391286PMC
May 2017
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