Publications by authors named "Yong-Fang Kuo"

382 Publications

Variation among hospitals in the continuity of care for older hospitalized patients: a cross-sectional cohort study.

BMC Health Serv Res 2021 Jun 5;21(1):552. Epub 2021 Jun 5.

Medical College of Wisconsin, Milwaukee, WI, USA.

Background: Little is known about how continuity of care for hospitalized patients varies among hospitals. We describe the number of different general internal medicine physicians seeing hospitalized patients during a medical admission and how that varies by hospital.

Methods: We conducted a retrospective study of a national 20% sample of Medicare inpatients from 01/01/16 to 12/31/18. In patients with routine medical admissions (length of stay of 3-6 days, no Intensive Care Unit stay, and seen by only one generalist per day), we assessed odds of receiving all generalist care from one generalist. We calculated rates for each hospital, adjusting for patient and hospital characteristics in a multi-level logistic regression model.

Results: Among routine medical admissions with 3- to 6-day stays, only 43.1% received all their generalist care from the same physician. In those with a 3-day stay, 50.1% had one generalist providing care vs. 30.8% in those with a 6-day stay. In a two-level (admission and hospital) logistic regression model controlling for patient characteristics and length of stay, the odds of seeing just one generalist did not vary greatly by patient characteristics such as age, race/ethnicity, comorbidity or reason for admission. There were large variations in continuity of care among different hospitals and geographic areas. In the highest decile of hospitals, the adjusted mean percentage of patients receiving all generalist care from one physician was > 84.1%, vs. < 24.1% in the lowest decile. This large degree of variation persisted when hospitals were stratified by size, ownership, location or teaching status.

Conclusions: Continuity of care provided by generalist physicians to medical inpatients varies widely among hospitals. The impact of this variation on quality of care is unknown.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1186/s12913-021-06584-0DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8180074PMC
June 2021

Assessing comorbidities and survival in HIV-infected and uninfected matched Medicare enrollees.

AIDS 2021 May 27. Epub 2021 May 27.

Office of Biostatistics, Department of Preventive Medicine and Population Health, University of Texas Medical Branch, Galveston, TX, USA Center for Interdisciplinary Research in Women's Health, The University of Texas Medical Branch at Galveston, TX, USA Department of Medicine, Baylor College of Medicine, Houston, TX, USA Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey VA Medical Center, Houston, TX, USA Department of Obstetrics & Gynecology, The University of Texas Medical Branch at Galveston, TX, USA.

Objective: People with HIV infection experience excessive mortality compared to their non-infected counterparts. It is unclear whether the impact of HIV infection on mortality varies by comorbidities or whether sex difference exists in this relationship. This study assessed the effect of newly diagnosed HIV infection on overall mortality among Medicare beneficiaries for both disabled and older adults (≥65 years old) based on their original entitlement.

Methods: We constructed a retrospective matched cohort using a 5% nationally representative sample of Medicare beneficiaries between 1996 and 2015. People with incident HIV diagnoses were individually matched to up to three controls based on demographics. Cox proportional hazards models adjusted for baseline demographics and comorbidities were used to assess the effect of HIV status on survival among four disabled groups by sex strata. Within each stratum, interactions between comorbidity variables and HIV status were examined.

Results: People with HIV, especially older females, had a higher prevalence of baseline comorbidities than controls. HIV-mortality association varied according to sex in older adults (p = 0.004). Comorbidity-HIV interactions were more pronounced in disabled groups (p < 0.0001). People with HIV with more chronic conditions had a less pronounced increase in the risk of death than those with fewer conditions, compared to uninfected controls.

Conclusion: Medicare enrollees with newly diagnosed HIV had more prevalent baseline comorbidities and were at higher risk of death than people without HIV. HIV infection has a more pronounced effect among those with fewer comorbidities. Sex differences in HIV-mortality association exist among older Medicare enrollees.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1097/QAD.0000000000002963DOI Listing
May 2021

The role of testosterone replacement therapy and statin use, and their combination, in prostate cancer.

Cancer Causes Control 2021 May 26. Epub 2021 May 26.

Deparment of Preventive Medicine and Population Health, University of Texas Medical Branch, Galveston, TX, USA.

Purpose: Previous studies have reported conflicting results in the associations of testosterone replacement therapy (TTh) and statins use with prostate cancer (PCa). However, the combination of these treatments with PCa stage and grade at diagnosis and prostate cancer-specific mortality (PCSM) and by race/ethnicity remains unclear.

Methods: We identified non-Hispanic White (NHW, N = 58,576), non-Hispanic Black (NHB, n = 9,703) and Hispanic (n = 4,898) men diagnosed with PCa in SEER-Medicare data 2007-2011. Pre-diagnostic prescription of TTh and statins was ascertained for this analysis. Multivariable-adjusted logistic and Cox proportional hazards models were used to evaluate the association of TTh and statins use with PCa stage and grade and PCSM.

Results: 22.5% used statins alone, 1.2% used TTh alone, and 0.8% used both. TTh and statins were independently, inversely associated with PCa advanced stage and high grade. TTh plus statins was associated with 44% lower odds of advanced stage PCa (OR 0.56, 95% CI 0.35-0.91). As expected, similar inverse associations were present in NHWs as the overall cohort is mostly comprised NHW men. In Hispanic men, statin use with or without TTh was inversely associated with aggressive PCa.

Conclusions: Pre-diagnostic use of TTh or statins, independent or in combination, was inversely associated with aggressive PCa, including in NHW and Hispanics men, but was not with PCSM. The findings for use of statins with aggressive PCa are consistent with cohort studies. Future prospective studies are needed to explore the independent inverse association of TTh and the combined inverse association of TTh plus statins on fatal PCa.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1007/s10552-021-01450-0DOI Listing
May 2021

State Variation in Chronic Opioid Use in Long-Term Care Nursing Home Residents.

J Am Med Dir Assoc 2021 May 19. Epub 2021 May 19.

Department of Internal Medicine, University of Texas Medical Branch, Galveston, TX, USA.

Objective: Policies and regulations on opioid use have evolved from being primarily state-to federally based. We examined the trends and variation in chronic opioid use among states and nursing homes.

Design: Retrospective cohort study.

Setting And Participants: We used the nursing home Minimum Data Set and Medicare claims from 2014 to 2018 and included long-term care nursing home residents from each year who had at least 120 days of consecutive stay.

Measurements: Chronic opioid use was defined as use for ≥90 days. Three-level hierarchical logistic regression models (resident, nursing home, state) were constructed to estimate intraclass correlation coefficient (ICC) at the state level and at the nursing home level. The ICC shows the proportion of variation in chronic opioid use that is attributable to states or nursing homes. All models were constructed separately for each calendar year and controlled for resident, nursing home, and state characteristics.

Results: We included 3,245,714 nursing home stays from 2014 to 2018, representing 1,502,131 unique residents. The stays ranged from 676,413 in 2014 to 594,874 in 2018, with residents contributing a maximum of 1 stay per year. Chronic opioid use among nursing home residents declined from 14.1% in 2014 to 11.4% in 2018. The variation (ICC) in chronic opioid use among states declined from 2.5% in 2014 to 1.7% in 2018. In contrast, the variation (ICC) among nursing homes increased from 5.6% in 2014 to 6.5% in 2018.

Conclusions And Implications: Variation in chronic opioid use declined by one-third at the state level but not at the nursing home level. National guidelines on opioid use and federal policies on opioid use may have contributed to reducing state-level variation in chronic opioid use.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.jamda.2021.04.016DOI Listing
May 2021

Smoking and risk of COVID-19 hospitalization.

Respir Med 2021 06 17;182:106414. Epub 2021 Apr 17.

Division of Pulmonary and Critical Care Medicine. Department of Internal Medicine, University of Texas Medical Branch. Galveston, TX, USA.

Rationale: The association between smoking status and severe Coronavirus Disease 2019 (COVID-19) remains controversial.

Objective: To assess the risk of hospitalization (as a marker of severe COVID-19) in patients by smoking status: former, current and never smokers, who tested positive for the Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-COV2) at an academic medical center in the United States.

Methods: We conducted a retrospective cohort study in patients with SARS-COV2 between March-1-2020 and January-31-2021 to identify the risk of hospitalization due to COVID-19 by smoking status.

Results: We identified 10216 SARS-COV2-positive patients with complete documentation of smoking habits. Within 14 days of a SARS-COV2 positive test, 1150 (11.2%) patients were admitted and 188 (1.8%) died. Significantly more former smokers were hospitalized from COVID-19 than current or never smokers (21.2% former smokers; 7.3% current smokers; 10.4% never smokers, p<0.0001). In univariable analysis, former smokers had higher odds of hospitalization from COVID-19 than never smokers (OR 2.31; 95% CI 1.94-2.74). This association remained significant when analysis was adjusted for age, race and gender (OR 1.28; 95% CI 1.06-1.55), but became non-significant when analysis included Body Mass Index, previous hospitalization and number of comorbidities (OR 1.05; 95% CI 0.86-1.29). In contrast, current smokers were less likely than never smokers to be hospitalized due to COVID-19.

Conclusions: Significantly more former smokers were hospitalized and died from COVID-19 than current or never smokers. This effect is mediated via age and comorbidities in former smokers.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.rmed.2021.106414DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8052507PMC
June 2021

Independent and joint effects of testosterone replacement therapy and statins use on the risk of prostate cancer among White, Black and Hispanic men.

Cancer Prev Res (Phila) 2021 Apr 20. Epub 2021 Apr 20.

University of Texas McGovern Medical School.

The associations of testosterone therapy (TTh) and statins use with prostate cancer (PCa) remain conflicted. However, the joint effects of TTh and statins use on the incidence of PCa, stage and grade at diagnosis, and PCa-specific mortality (PCSM) have not been studied. We identified White (N=74181), Black (N=9157) and Hispanic (N=3313) men diagnosed with PCa in SEER-Medicare 2007-2016. Pre-diagnostic prescription of TTh and statins was ascertained for this analysis. Weighted multivariable-adjusted conditional logistic and Cox proportional hazards models evaluated the association of TTh and statins with PCa, including statistical interactions between TTh and statins. We found that TTh (OR = 0.74, 95% CI: 0.68 - 0.81) and statins (OR = 0.77, 95% CI: 0.0.75 - 0.88) were inversely associated with incident PCa. Similar inverse associations were observed with high-grade and advanced PCa in relation to TTh and statins use. TTh plus statins was inversely associated with incident PCa (OR = 0.53, 95% CI: 0.48 - 0.60), high-grade (OR = 0.43, 95% CI: 0.37 - 0.49) and advanced PCa (OR = 0.44, 95% CI: 0.35 - 0.55). Similar associations were present in White and Black men, but among Hispanics statins were associated with PCSM. Pre-diagnostic use of TTh or statins, independent or combined, was inversely associated with incident and aggressive PCa overall and in NHW and NHB men. Findings for statins and aggressive PCa are consistent with previous studies. Future studies need to confirm the independent inverse association of TTh and the joint inverse association of TTh plus statins on risk of PCa in understudied populations.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1158/1940-6207.CAPR-21-0040DOI Listing
April 2021

Relationship between Nursing Home Compare Improvement in Function Quality Measure and Physical Recovery after Hip Replacement.

Arch Phys Med Rehabil 2021 Apr 1. Epub 2021 Apr 1.

University of Texas Medical Branch, School of Health Professions, Division of Rehabilitation Sciences; University of Texas Medical Branch, Sealy Center on Aging.

Objective: To determine if patients with a total or partial hip replacement admitted to a skilled nursing facility (SNF) after the improvement in function quality measure was added to Nursing Home Compare in July 2016 have greater physical recovery than patients admitted before July 2016.

Design: Pre (1/1/2015-6/30/2016) versus post (7/1/2016-12/31/2017) design.

Setting: Skilled Nursing Facilities (n=12,829).

Participants: Medicare fee-for-service beneficiaries discharged from acute hospitals to SNF following hip replacement between 01/01/2015 and 12/31/2017 (N=106,832).

Main Outcome Measures: The 5-day and 14-day Minimum Data Set assessments were used to calculate total scores for the quality measure, self-care, mobility, and balance. We calculated the average adjusted change per 10-days and any improvement between the 5-day and 14-day assessments.

Results: The average adjusted changer per 10-days for the quality measure total score for patients admitted before July 2016 and after July 2016 were 1.00 points (standard error [SE]=0010) and 1.06 points (SE=0.010), respectively (p<0.01). This was a relative increase of 6.0%. Among patients admitted to a SNF before July 2016, 44.4% (SE=0.06) had any improvement in the quality measure total score compared to 45.5% (SE=0.23) of patients admitted after July 2016 (p<0.01). This was a relative increase of 2.5%. The adjusted change per 10-days and percentage of patients who had any improvement in the total scores for self-care, mobility, and balance were all significantly higher after July 2016.

Conclusions: Patients admitted to a SNF following a hip replacement after July 2016 had greater physical recovery than patients admitted before the improvement in function quality measure was added to Nursing Home Compare.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.apmr.2021.03.012DOI Listing
April 2021

Overdose deaths from nonprescribed prescription opioids, heroin, and other synthetic opioids in Medicare beneficiaries.

J Subst Abuse Treat 2021 05 7;124:108282. Epub 2021 Jan 7.

Department of Internal Medicine and Sealy Center on Aging, University of Texas Medical Branch, Galveston, TX 77555-0177, United States of America; Department of Preventive Medicine and Population Health, University of Texas Medical Branch, Galveston, TX 77555-1148, United States of America.

Importance: Opioid use disorder in the United States' Medicare population increased from 10 to 24 per 1000 from 2012 to 2018. Understanding the changes in the patterns of opioid overdose mortality over time holds broad clinical and public health relevance.

Objective: To examine trends and correlates of opioid overdose deaths from nonprescribed prescription opioids, heroin, and other synthetic opioids.

Design, Setting And Participants: The study used Medicare-National Death Index linked data from a 20% national sample to identify a retrospective cohort who died from opioid overdose in 2012-2016. The study analyzed data from December 2019 to March 2020.

Main Outcome And Measures: We examined type of opioid overdose deaths; percentage of opioid deaths without documented opioid prescriptions in the prior 6 months; and percentage of deaths from heroin or synthetic opioids among people on long-term prescription opioids whose prescribers reduced or subsequently discontinued their opioids. The study also calculated the proportion receiving medication for addiction treatment. The study included demographic characteristics and 15 chronic or potentially disabling conditions associated with overall opioid overdose deaths.

Results: Among 6932 Medicare enrollees who died from opioid overdose in 2012-2016, the mean (SD) age was 52.9 (12.1) years, 45.4% were women, and 82.4% were white. The number of opioid overdose deaths increased from 1159 in 2012 to 1697 in 2016. In the adjusted analyses, opioid deaths occurring in 2016 were 2.6 times more likely to be due to heroin or other synthetic opioids than opioid deaths occurring in 2012. The prescription opioid deaths occurring without a documented opioid prescription in the 6 months before death increased from 6.8% in 2012 to 11.7% in 2016. Factors associated with such deaths, assessed in a stepwise logistic regression model, included metropolitan or rural residence and diagnosis of opioid use disorder. Among people with long-term opioid use whose prescription opioids were reduced in the 6 months before death, the percentage of deaths attributable to heroin and other synthetic opioids increased from 17% in 2012 to 47% in 2016. Factors associated with such deaths, assessed in a stepwise logistic regression model, included diagnosis of hepatitis and opioid use disorder. Less than 10% of these enrollees received medication for addiction treatment.

Conclusion: There were substantial increases in patients' obtaining opioid analgesics from unlicensed sources and in overdose deaths from nonprescribed opioids during the study period (2012-2016). Increased access to pain management and opioid use disorder treatments is critical to reducing the opioid overdose deaths in the United States.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.jsat.2021.108282DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8004556PMC
May 2021

Potentially inappropriate medication prescribing by nurse practitioners and physicians.

J Am Geriatr Soc 2021 Mar 22. Epub 2021 Mar 22.

Department in Internal Medicine, Division of Geriatrics and Palliative Care, University of Texas Medical Branch, Galveston, Texas, USA.

Background: Potentially inappropriate medication (PIM) use is a risk factor for hospitalization and mortality. However, there were few studies focusing on the impact of provider type on PIM use.

Objective: We aimed to estimate the initial and refill PIM prescribing rate for physician visits and nurse practitioner (NP) visits and the impact of provider type on PIM prescribing.

Research Design: We used 100% Texas Medicare data to define physician visits and NP visits in 2016. The rate of visits with a PIM prescription from the same provider was measured, distinguishing between initial and refill prescription to estimate the PIM rate and adjusted odds ratio (OR) by provider type.

Results: There were 24.1 per 1000 visits with a prescription for a PIM: 9.0 per 1000 visits for an initial PIM and 15.1 per 1000 visits for a refill PIM. A visit to an NP was less likely to result in an initial (OR = 0.74, 95% confidence interval [CI] = 0.70-0.79) or refill (OR = 0.54, 95% CI = 0.51-0.57) PIM. The association of lower odds of receiving a prescription for an initial PIM from an NP was substantially stronger among black enrollees than white enrollees (OR = 0.44, 95%CI = 0.30-0.65 for blacks and OR = 0.73, 95%CI = 0.68-0.78 for white enrollees). The association of an NP provider with lower odds of receiving a PIM refill was more pronounced in older patients and in those with more comorbidities.

Conclusions: NPs prescribed fewer initial PIMs and were less likely to refill a PIM after an outpatient visit than physicians. The lower odds of receiving PIMs during an NP visit varied by age, race/ethnicity, rurality, and number of comorbidities.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1111/jgs.17120DOI Listing
March 2021

Association of Occupational and Physical Therapy With Duration of Prescription Opioid Use After Hip or Knee Arthroplasty: A Retrospective Cohort Study of Medicare Enrollees.

Arch Phys Med Rehabil 2021 Feb 19. Epub 2021 Feb 19.

Department of Preventive Medicine and Community Health, University of Texas Medical Branch, Galveston, TX.

Objective: To establish whether nonpharmacologic interventions, such as occupational and physical therapy, were associated with a shorter duration of prescription opioid use after hip or knee arthroplasty.

Design: This retrospective cohort study used data from a national 5% Medicare sample database between January 1, 2010 and December 31, 2015.

Setting: Home health or outpatient.

Participants: Adults 66 years or older with an inpatient total hip (n=4272) or knee (n=9796) arthroplasty (N=14,068).

Interventions: We dichotomized patients according to whether they had received any nonpharmacologic pain intervention within 1 year after hospital discharge (eg, occupational or physical therapy evaluation). Using Cox proportional hazards, we treated exposure to nonpharmacologic interventions as time dependent to determine if skilled therapy was associated with duration of opioid use.

Main Outcome Measures: Duration of prescription opioid use.

Results: Median time to begin nonpharmacologic interventions was 91 days (95% confidence interval [CI], 74-118d) for hip and 27 days (95% CI, 27-28d) for knee arthroplasty. Median time to discontinue prescription opioids was 16 days (hip: 95% CI, 15-16d) and 30 days (knee: 95% CI, 29-31d). Nonpharmacologic interventions delivered with home health increased the likelihood of discontinuing opioids after hip (hazard ratio [HR], 1.15; 95% CI, 1.01-1.30) and knee (HR, 1.10; 95% CI, 1.03-1.17) arthroplasty. A sensitivity analysis found these estimates to be robust and conservative.

Conclusions: Occupational and physical therapy with home health was associated with a shorter duration of prescription opioid use after hip and knee arthroplasty. Occupational and physical therapy can address pain and sociobehavioral factors associated with postsurgical opioid use.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.apmr.2021.01.086DOI Listing
February 2021

A brief educational intervention can improve nursing students' knowledge of the human papillomavirus vaccine and readiness to counsel.

Hum Vaccin Immunother 2021 Jul 30;17(7):1952-1960. Epub 2021 Jan 30.

Center for Interdisciplinary Research in Women's Health (ABB, JMH, MC, YFK), Department of Obstetrics and Gynecology (ABB, JMH, MC), Office of Biostatistics, Department of Preventive Medicine and Community Health (YFK), School of Nursing (PR, DLJ), The University of Texas Medical Branch, Galveston, TX, USA.

Provider recommendation is a primary reason for patient uptake of the human papillomavirus (HPV) vaccine. Most provider-focused educational interventions are focused on physicians, even though nurses are also important sources of vaccine-related information for their patients. This study examined whether a HPV educational intervention could improve nursing students' HPV knowledge, beliefs, and comfort with counseling. The same lecture on HPV and HPV vaccination was given to both medical and nursing students. To determine the effects of the lecture, students were asked to complete identical pre- and post-lecture tests with questions on demographics, knowledge, attitudes, and comfort with counseling on the HPV vaccine. Pre- and post-lecture test scores were compared between nursing and medical students to assess whether there were differences in pre-lecture test scores and/or changes in post-lecture test scores. On the pre-lecture tests, fewer nursing students responded correctly to knowledge questions, indicated positive attitudes or comfort with counseling about the HPV vaccine compared to medical students. However, similar frequencies of nursing and medical students responded correctly to knowledge questions and indicated a positive attitude, as well as a high comfort level with counseling on the post-lecture tests. Study results show that integrating lectures in a nursing program curriculum could be a feasible way to increase students' HPV knowledge. Having health-care providers with similar levels of knowledge, attitudes, and comfort with counseling on HPV vaccination is ideal, as all share the responsibility of recommending the vaccine to patients.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1080/21645515.2020.1852871DOI Listing
July 2021

Use of psychotropic drugs among older patients with bladder cancer in the United States.

Psychooncology 2021 Jun 20;30(6):832-843. Epub 2021 Feb 20.

Division of Urology, The University of Texas Medical Branch at Galveston, Galveston, Texas, USA.

Objective: Older patients diagnosed with cancer are at increased risk of physical and emotional distress; however, prescription utilization patterns largely remain to be elucidated. Our objective was to comprehensively assess prescription patterns and predictors in older patients with bladder cancer.

Methods: A total of 10,516 older patients diagnosed with clinical stage T1-T4a, N0, M0 bladder urothelial carcinoma from 1 January 2008 to 31 December 2012 from the Surveillance, Epidemiology, and End Results (SEER)-Medicare were analyzed. We used multivariable analysis to determine predictors associated with psychotropic prescription rates (one or more). Medication possession ratio (MPR) was used as an index to measure adherence in intervals of 3 months, 6 months, 1 year, and 2 years. Evaluation of psychotropic prescribing patterns and adherence across different drugs and demographic factors was done.

Results: Of the 10,516 older patients, 5621 (53%) were prescribed psychotropic drugs following cancer diagnosis. Overall, 3972 (38%) patients had previous psychotropic prescriptions prior to cancer diagnosis, and these patients were much more likely to receive a post-cancer diagnosis prescription. Prescription rates for psychotropic medications were higher among patients with higher stage BC (p < 0.001). Gamma aminobutyric acid modulators/stimulators and serotonin reuptake inhibitors/stimulators were the highest prescribed psychotropic drugs in 21% of all patients. Adherence for all drugs was 32% at 3 months and continued to decrease over time.

Conclusion: Over half of the patients received psychotropic prescriptions within 2 years of their cancer diagnosis. Given the chronicity of psychiatric disorders with observed significantly low adherence to medications that warrants an emphasis on prolonged patient monitoring and further investigation.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1002/pon.5641DOI Listing
June 2021

US national trends in prescription opioid use after burn injury, 2007 to 2017.

Surgery 2021 Jan 17. Epub 2021 Jan 17.

Department of Preventive Medicine and Population Health, University of Texas Medical Branch, Galveston, TX; Department of Internal Medicine, Division of Geriatrics and Palliative Medicine, University of Texas Medical Branch, Galveston, TX; Sealy Center on Aging, University of Texas Medical Branch, Galveston, TX; Institute for Translational Sciences, University of Texas Medical Branch, Galveston, TX. Electronic address:

Background: Opioid misuse and overdose in the United States remain a public health emergency. Overprescribing has been recognized as a significant contributor to the epidemic. Opioids are the mainstay for pain management after burn; however, to date, no large-scale nationally representative study has evaluated outpatient opioid prescribing practices in this population.

Methods: A retrospective study was conducted of patients up to 65 years old with burn injuries between 2007 and 2017 using national commercial insurance data. The primary outcome was initial opioid prescribing after burn injury. Secondary outcomes were total days' supply, oral daily morphine milligram equivalents, and number of refills.

Results: Of the 140,753 patients with burns, 34,685 (24.6%) received an opioid prescription. The odds of prescription opioid use were lower in 2015, 2016, and 2017 compared with 2007. Interactions with age, severity (P < .0001), and region (P = .003) showed significant variation in rates of decline from 2007 to 2017, with the steepest decline in those aged <20 and in residents of Northeast United States. Prescribing rates remained stable over time among those with more severe burn injuries. The significant decline in daily opioid morphine milligram equivalents after 2013 was paralleled by an increase in days of supply (P values <.005). The odds of refill declined in 2016 and 2017.

Conclusion: While opioid prescribing after burn has declined in the past decade, significant variation remains among regions and age groups, suggesting a need to develop uniform guidelines to improve the quality of opioid prescribing and pain management protocols in burn patients.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.surg.2020.12.011DOI Listing
January 2021

The impact of long-term opioid use on the risk and severity of COVID-19.

J Opioid Manag 2020 Nov-Dec;16(6):401-404

Division of Geriatrics and Palliative Medicine, Department of Internal Medicine and Sealy Center on Aging; De-partment of Preventive Medicine and Community Health, University of Texas Medical Branch (UTMB), Galveston, Texas.

Based on evidence of the immunosuppressive effects of chronic opioids, long-term users of prescription and illicit opioids comprise an unrecognized but growing population of Americans with compromised immune function and respiratory depression who may be at high risk of infection with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and coronavirus disease 19 (COVID-19)-related hospitalization, prolonged ICU stay, adverse events, and death. This perspective is of broad clinical and public health importance because the US has the highest population of long-term users of prescription opioids, a sequel of a decade-long practice of opioid overprescribing in the US. For long-term opioid users who are hospitalized for COVID-19, clinicians face clinical challenges arising from the suppressive effects of opioids on the respiratory and immune functions, as well as the potential for adverse drug-drug interaction when opioids have to be continued in long-term users. More research is needed to further understand the association of long-term opioid use and susceptibility to COVID-19 and other emerging infections.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.5055/jom.2020.0597DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8011291PMC
January 2021

Regional and temporal variation in receipt of long-term opioid therapy among older breast, colorectal, lung, and prostate cancer survivors in the United States.

Cancer Med 2021 03 9;10(5):1550-1561. Epub 2021 Jan 9.

Department of Preventive Medicine and Population Health, Office of Biostatistics, University of Texas Medical Branch - Galveston, Galveston, TX, USA.

Background: Older cancer survivors have high rates of long-term opioid therapy (≥90 days/year). However, the geographical and temporal variation in long-term opioid therapy rates for older cancer survivors is not known.

Methods: A retrospective cohort study was conducted using SEER-Medicare data. Persons aged ≥66 years, diagnosed with breast, colorectal, lung, or prostate cancer from 1991 to 2011, and alive ≥5 years after diagnosis were included. Persons were followed from 1/1/2008 until 12/31/2016. Persons were assigned to a census region in their state of residence each year. Individuals who were covered by an opioid prescription for at least 90 days in a calendar year were classified as having received long-term opioid therapy. Multivariable analysis was conducted using generalized estimating equations.

Results: Temporal trends significantly varied by region (p < 0.0001) and opioid-naïve status (p < 0.0001). Compared to 2013, opioid-naïve cancer survivors in the south and non-naïve survivors in the south and west experienced significant declines in long-term opioid therapy in 2015 and 2016. Significant declines were observed in 2016 for opioid-naïve and non-naïve cancer survivors residing in the northeast and among opioid-naïve cancer survivors living in the Midwest.

Conclusion: The annual trends in the receipt of long-term opioid therapy significantly varied by region among older cancer survivors. Variation in a clinical practice suggests the need for more research and interventions to improve efficiency, process, cost, and quality of care.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1002/cam4.3709DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7940244PMC
March 2021

Higher Frequency of Hospital-Acquired Infections but Similar In-Hospital Mortality Among Admissions With Alcoholic Hepatitis at Academic vs. Non-academic Centers.

Front Physiol 2020 3;11:594138. Epub 2020 Dec 3.

Department of Medicine, University of South Dakota Sanford School of Medicine, Sioux Falls, SD, United States.

Background: Alcoholic hepatitis (AH) is a unique syndrome characterized by high short-term mortality. The impact of the academic status of a hospital (urban and teaching) on outcomes in AH is unknown.

Methods: National Inpatient Sample dataset (2006-2014) on AH admissions stratified to academic center (AC) or non-academic center (NAC) and analyzed for in-hospital mortality (IHM), hospital resource use, length of stay in days (d), and total charges (TC) in United States dollars (USD). Admission year was stratified to 2006-2008 (TMI), 2009-2011 (TM2), and 2012-2014 (TM3).

Results: Of 62,136 AH admissions, the proportion at AC increased from 46% in TM1 to 57% in TM3, Armitage trend, < 0.001. On logistic regression, TM3, younger age, black race, Medicaid and private insurance, and development of acute on chronic liver failure (ACLF) were associated with admission to an AC. Of 53,264 admissions propensity score matched for demographics, pay status, and disease severity, admissions to AC vs. NAC (26,622 each) were more likely to have liver disease complications (esophageal varices, ascites, and hepatic encephalopathy) and hospital-acquired infections (HAI), especially and ventilator-associated pneumonia. Admissions to AC were more likely transfers from outside hospital (1.6% vs. 1.3%) and seen by palliative care (4.8% vs. 3.3%), < 0.001. Use of endoscopy, dialysis, and mechanical ventilation were similar. With similar IHM comparing AC vs. NAC (7.7% vs. 7.8%, = 0.93), average LOS and number of procedures were higher at AC (7.7 vs. 7.1 d and 2.3 vs. 1.9, respectively, < 0.001) without difference on total charges ($52,821 vs. $52,067 USD, = 0.28). On multivariable logistic regression model after controlling for demographics, ACLF grade, and calendar year, IHM was similar irrespective of academic status of the hospital, HR (95% CI): 1.01 (0.93-1.08, = 0.70). IHM decreased over time, with ACLF as strongest predictor. A total of 63 and 22% were discharged to home and skilled nursing facility, respectively, without differences on academic status of the hospital.

Conclusion: Admissions with AH to AC compared to NAC have higher frequency of liver disease complications and HAI, with longer duration of hospitalization. Prospective studies are needed to reduce HAI among hospitalized patients with AH.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.3389/fphys.2020.594138DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7744884PMC
December 2020

Validating a novel score based on interaction between ACLF grade and MELD score to predict waitlist mortality.

J Hepatol 2021 Jun 14;74(6):1355-1361. Epub 2020 Dec 14.

Department of Medicine, University of South Dakota Sanford School of Medicine, Sioux Falls, SD, USA; Division of Transplant Hepatology, Avera Transplant Institute, Sioux Falls, SD, USA. Electronic address:

Background & Aims: Among candidates listed for liver transplant (LT), the model for end-stage liver disease (MELD) score may not capture acute-on-chronic liver failure (ACLF) severity. Data on the interaction between ACLF and MELD score in predicting waitlist mortality are scarce.

Methods: We analyzed the UNOS database (01/2002 to 06/2018) for LT listings in adults with cirrhosis and ACLF (without hepatocellular carcinoma). ACLF grades 1, 2, 3a, and 3b- were defined using the modified EASL-CLIF criteria.

Results: Of 18,416 candidates with ACLF at listing (mean age 54 years, 69% males, 63% Caucasians), 90-day waitlist mortality (patient death or being too sick for LT) was 21.6% (18%, 20%, 25%, and 39% for ACLF grades 1, 2, 3a, and 3b, respectively). Using a Fine and Gray regression model, we identified an interaction between MELD and ACLF grade, with ACLF having a higher impact at lower MELD scores. Other variables included candidate's age, sex, liver disease etiology, listing MELD, ACLF grade, obesity, and performance status. A score developed using parameter estimates from the interaction model on the derivation cohort (n = 9,181) stratified the validation cohort (n = 9,235) into quartiles: Q1 (score <10.42), Q2 (10.42-12.81), Q3 (12.82-15.50), and Q4 (>15.50). Waitlist mortality increased with each quartile from 13%, 18%, 23%, and 36%, respectively. Observed vs. expected waitlist mortality deciles in the validation cohort showed good calibration (goodness of fit p = 0.98) and correlation (R = 0.99).

Conclusion: Among selected candidates who have ACLF at listing, MELD score and ACLF interact in predicting cumulative risk of 90-day waitlist mortality, with higher impact of ACLF grade at lower listing MELD score. Validating these findings in large prospective studies will support consideration of both MELD and ACLF when prioritizing transplant candidates and allocating liver grafts.

Lay Summary: In patients with cirrhosis listed for liver transplantation, the presence of multiorgan failure, a condition referred to as acute-on-chronic liver failure, is associated with high waiting list mortality rates. Current organ allocation policy disadvantages patients with this condition. This study describes and validates a new scoring method that performs better than the currently available scoring systems. Further validation of this approach may reduce the deaths of patients with cirrhosis and acute-on-chronic liver failure on the transplant waiting list.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.jhep.2020.12.003DOI Listing
June 2021

Assessing Association Between Team Structure and Health Outcome and Cost by Social Network Analysis.

J Am Geriatr Soc 2020 Dec 1. Epub 2020 Dec 1.

Department of Internal Medicine and Sealy Center on Aging, University of Texas Medical Branch, Galveston, Texas, USA.

Background/objective: To assess the impact of team structure composition and degree of collaboration among various providers on process and outcomes of primary care.

Design: Cross-sectional study.

Setting: Data from 20% randomly selected primary care service areas in the 2015 Medicare claims were used to identify primary care practices.

Participants: 449,460 patients with diabetes, heart failure, or chronic obstructive pulmonary disease cared for by the identified primary care practices.

Measurements: Social network analysis measures, including edge density, degree centralization, and betweenness centralization for each practice.

Results: When compared with practices with MDs and nurse practitioners (NPs) or/and physicians assistants (PAs), the practices with MDs had only lower degree of centralization and higher MD-to-MD connectedness. Within the primary care practices comprising MDs, NPs, or/and PAs, the nonphysician providers were more connected (measured as edge density) to all providers in the practice but with higher degree of centralization compared with the MDs in the practice. After adjusting for patient characteristics and type of practice, higher edge density was associated with lower odds of hospitalization (odds ratio (OR) = 0.89, 95% confidence interval (CI) = 0.79-0.99), emergency department (ER) admission (OR = 0.80, 95% CI = 0.70-0.92), and total spending (cost ratio (CR) = 0.86, standard error of the mean (SE) = 0.038). Conversely, higher degree centralization was associated with higher rates of hospitalization (OR = 1.15, 95% CI = 1.03-1.28), ER admission (OR = 1.23, 95% CI = 1.08-1.40), and total spending (CR = 1.14, SE = 0.037). However, higher degree centralization was associated with lower rates of potentially inappropriate medications (OR = 0.90, 95% CI = 0.81-0.99). Team leadership by an NP versus an MD was similar in the rate of ER admissions, hospitalizations, or total spending.

Conclusion: Our findings showed that highly connected primary care practices with high collaborative care and less top-down MD-centered authority have lower odds of hospitalization, fewer ER admissions, and less total spending; findings likely reflecting better communication and more coordinated care of older patients.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1111/jgs.16962DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8166955PMC
December 2020

How to Identify Team-based Primary Care in the United States Using Medicare Data.

Med Care 2021 02;59(2):118-122

Preventive Medicine and Population Health.

Background: Studying team-based primary care using 100% national outpatient Medicare data is not feasible, due to limitations in the availability of this dataset to researchers.

Methods: We assessed whether analyses using different sets of Medicare data can produce results similar to those from analyses using 100% data from an entire state, in identifying primary care teams through social network analysis. First, we used data from 100% Medicare beneficiaries, restricted to those within a primary care services area (PCSA), to identify primary care teams. Second, we used data from a 20% sample of Medicare beneficiaries and defined shared care by 2 providers using 2 different cutoffs for the minimum required number of shared patients, to identify primary care teams.

Results: The team practices identified with social network analysis using the 20% sample and a cutoff of 6 patients shared between 2 primary care providers had good agreement with team practices identified using statewide data (F measure: 90.9%). Use of 100% data within a small area geographic boundary, such as PCSAs, had an F measure of 83.4%. The percent of practices identified from these datasets that coincided with practices identified from statewide data were 86% versus 100%, respectively.

Conclusions: Depending on specific study purposes, researchers could use either 100% data from Medicare beneficiaries in randomly selected PCSAs, or data from a 20% national sample of Medicare beneficiaries to study team-based primary care in the United States.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1097/MLR.0000000000001478DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7855067PMC
February 2021

Proximity to Oil Refineries and Risk of Cancer: A Population-Based Analysis.

JNCI Cancer Spectr 2020 Dec 7;4(6):pkaa088. Epub 2020 Oct 7.

Department of Surgery, The University of Texas Medical Branch at Galveston, Galveston, TX, USA.

Background: The association between proximity to oil refineries and cancer rate is largely unknown. We sought to compare the rate of cancer (bladder, breast, colon, lung, lymphoma, and prostate) according to proximity to an oil refinery in Texas.

Methods: A total of 6 302 265 persons aged 20 years or older resided within 30 miles of an oil refinery from 2010 to 2014. We used multilevel zero-inflated Poisson regression models to examine the association between proximity to an oil refinery and cancer rate.

Results: We observed that proximity to an oil refinery was associated with a statistically significantly increased risk of incident cancer diagnosis across all cancer types. For example, persons residing within 0-10 (risk ratio [RR] = 1.13, 95% confidence interval [CI] = 1.07 to 1.19) and 11-20 (RR = 1.05, 95% CI = 1.00 to 1.11) miles were statistically significantly more likely to be diagnosed with lymphoma than individuals who lived within 21-30 miles of an oil refinery. We also observed differences in stage of cancer at diagnosis according to proximity to an oil refinery. Moreover, persons residing within 0-10 miles were more likely to be diagnosed with distant metastasis and/or systemic disease than people residing 21-30 miles from an oil refinery. The greatest risk of distant disease was observed in patients diagnosed with bladder cancer living within 0-10 vs 21-30 miles (RR = 1.30, 95% CI = 1.02 to 1.65), respectively.

Conclusions: Proximity to an oil refinery was associated with an increased risk of multiple cancer types. We also observed statistically significantly increased risk of regional and distant/metastatic disease according to proximity to an oil refinery.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1093/jncics/pkaa088DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7691047PMC
December 2020

Quantitative and qualitative assessment of an all-inclusive postpartum human papillomavirus vaccination program.

Am J Obstet Gynecol 2021 05 25;224(5):504.e1-504.e9. Epub 2020 Nov 25.

Center for Interdisciplinary Research in Women's Health, The University of Texas Medical Branch at Galveston, Galveston, TX; Department of Pediatrics, The University of Texas Medical Branch at Galveston, Galveston, TX.

Background: A postpartum human papillomavirus vaccination program was locally implemented to address low initiation rates among young adults. Within 20 months, the program achieved high vaccine initiation and series completion rates. Based on the program's success, it was expanded to all 36 counties served by a public hospital.

Objective: This study aimed to conduct a quantitative and qualitative evaluation to examine the success and limitations of the program when expanded from 1 county to 36 counties, many of which are home to rural and medically underserved communities.

Study Design: Patient navigators reviewed the electronic medical records and immunization registry records of women aged ≤26 years, who delivered an infant at the public hospital, to determine whether they needed to initiate or complete the human papillomavirus vaccine series. Eligible women were counseled and offered the human papillomavirus vaccine during their hospital stay. Patient navigators scheduled follow-up injections in addition to the mother's postpartum or her infant's well-child visits, made reminder phone calls, and rescheduled missed appointments. Descriptive statistics, including frequencies and proportions, were used for patients approached in the initial and expansion programs. Frequencies from the initial and expansion programs were examined separately. Qualitative interviews were conducted with the clinic staff to evaluate the program. The qualitative analyses were conducted using NVivo (QSR International, Melbourne, Australia, version 10).

Results: Both initial and expanded programs achieved vaccine completion rates above 70%. Of the 2631 eligible postpartum women enrolled in the initial program, 785 (30%) had already been fully vaccinated. Of the remaining 1846 women, 1265 (69%) women received their first dose, and 196 (11%) women received their second or third dose on the postpartum unit. Of the 1461 women who received at least 1 dose through the initial program, 1124 (77%) completed all 3 doses. Of the 4330 eligible postpartum women enrolled in the expanded program, 886 (21%) had already been fully vaccinated. Of the remaining 3444 women, 2284 (66%) received their first dose, and 343 (10%) received their second or third dose on the postpartum unit. Of the 2627 women receiving at least 1 dose through the expanded program, 1932 (74%) completed all 3 doses. Clinic staff interviewed felt the program benefited the postpartum unit and clinics, because it increased patient knowledge of the vaccine, increased patient volume for vaccination, and gave healthcare providers more time to focus on other tasks.

Conclusion: Human papillomavirus vaccination on the postpartum unit is an effective way to increase catchup rates and is well accepted by healthcare providers. High completion rates can be achieved if adequate support is provided, even among patients residing in rural or underserved areas who need extensive support to access primary healthcare services. Although this particular program may be considered costly, it is overall effective because the vaccine prevents 5 different types of cancer in women. The inclusion of human papillomavirus vaccination in routine postpartum care is a relatively easy way to reach many adults not vaccinated at a younger age and could help address low vaccination rates among young women in the United States, including hard-to-reach populations.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.ajog.2020.11.033DOI Listing
May 2021

Characteristics Associated with Feeding Tube Placement: Retrospective Cohort Study of Texas Nursing Home Residents with Advanced Dementia.

J Am Med Dir Assoc 2020 Nov 22. Epub 2020 Nov 22.

University of Texas Medical Branch Division of Geriatrics and Palliative Care; Galveston, Texas, United States. Electronic address:

Objectives: To investigate resident-level, provider-type, nursing home (NH), and regional factors associated with feeding tube (FT) placement in advanced dementia.

Design: Retrospective cohort study.

Setting And Participants: NH residents in Texas with dementia diagnosis and severe cognitive impairment (N = 20,582).

Methods: This study used 2011-2016 Texas Medicare data to identify NH residents with a stay of at least 120 days who had a diagnosis of dementia on Long Term Care Minimum Data Set (MDS) evaluation and severe cognitive impairment on clinical score. Multivariable repeated measures analyses were conducted to identify associations between FT placement and resident-level, provider-type, NH, and regional factors.

Results: The prevalence of FT placement in advanced dementia in Texas between 2011 and 2016 ranged from 12.5% to 16.1% with a nonlinear trend. At the resident level, the prevalence of FT decreased with age [age > 85 years, prevalence ratio (PR) 0.60, 95% confidence interval (CI) 0.52-0.69] and increased among residents who are black (2.74, 95% CI 2.48-3.03) or Hispanic (PR 1.91, 95% CI 1.71-2.13). Residents cared for by a nurse practitioner or physician assistant were less likely to have an FT (PR 0.90, 95% CI 0.85-0.96). No facility characteristics were associated with prevalence of FT placement in advanced dementia. There were regional differences in FT placement with the highest use areas on the Texas-Mexico border and in South and East Texas (Harlingen border area, PR 4.26, 95% CI 3.69-4.86; San Antonio border area, PR 3.93, 95% CI 3.04-4.93; Houston, PR 2.17, 95% CI 1.87-2.50), and in metro areas (PR 1.36, 95% CI 1.22-1.50).

Conclusions And Implications: Regional, race, and ethnic variations in prevalence of FT use among NH residents suggest opportunities for clinicians and policy makers to improve the quality of end-of-life care by especially considering other palliative care measures for minorities living in border towns.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.jamda.2020.10.033DOI Listing
November 2020

Factors associated with endometrial cancer and hyperplasia among middle-aged and older Hispanics.

Gynecol Oncol 2021 01 19;160(1):16-23. Epub 2020 Nov 19.

Department of Preventive Medicine and Population Health, USA.

Objective: While disparities in endometrial hyperplasia and endometrial cancer are well documented in Blacks and Whites, limited information exists for Hispanics. The objective is to describe the patient characteristics associated with endometrial hyperplasia symptoms, endometrial hyperplasia with atypia and endometrial cancer, and assess factors contributing to racial/ethnic differences in disease outcomes.

Methods: This single-center, retrospective study included women aged ≥50 years with ≥ two encounters for endometrial hyperplasia symptoms, endometrial hyperplasia with atypia and endometrial cancer between 2012 and 2016. Multivariate logistic regression models evaluated the predictors of endometrial cancer and hyperplasia.

Results: We included 19,865 women (4749 endometrial hyperplasia symptoms, 71 endometrial hyperplasias with atypia, 201 endometrial cancers) with mean age of 60.45 years (SD 9.94). The odds of endometrial hyperplasia symptoms were higher in non-Hispanic Blacks (Odds Ratio [OR] 1.56, 95% Confidence Interval [CI] 1.20-1.72), Hispanics (OR 1.35, 95% CI 1.22-1.49), family history of female cancer (OR 1.25, 95% CI 1.12-1.39), hypertension (OR 1.24, 95% CI 1.14-1.35), and birth control use (OR 1.29, 95% CI 1.15-1.43). Odds of endometrial cancer and atypical hyperplasia increased for ages 60-64 (OR 7.95, 95% CI 3.26-19.37; OR 3.66, 95% 1.01-13.22) and being obese (OR 1.61, 95% CI 1.08-2.41; OR: 6.60, 95% CI 2.32-18.83). Odds of endometrial cancer increased with diabetes (OR 1.68, 95% CI 1.22-2.32).

Conclusion(s): Patients with obesity and diabetes had increased odds of endometrial cancer and hyperplasia with atypia. Further study is needed to understand the exogenous estrogen effect contributing to the increased incidence among Hispanics.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.ygyno.2020.10.033DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8142520PMC
January 2021

Processes and outcomes of diabetes mellitus care by different types of team primary care models.

PLoS One 2020 5;15(11):e0241516. Epub 2020 Nov 5.

Center for Interdisciplinary Research in Women's Health, The University of Texas Medical Branch at Galveston, Galveston, Texas, United States of America.

Background: Team care improves processes and outcomes of care, especially for patients with complex medical conditions that require coordination of care. This study aimed to compare the processes and outcomes of care provided to older patients with diabetes by primary care teams comprised of only primary care physicians (PCPs) versus team care that included nurse practitioners (NPs) or physician assistants (PAs).

Methods: We studied 3,524 primary care practices identified via social network analysis and 306,741 patients ≥66 years old diagnosed with diabetes in or before 2015 in Medicare data. Guideline-recommended diabetes care included eye examination, hemoglobin A1c test, and nephropathy monitoring. High-risk medications were based on recommendations from the American Geriatrics Society Beers Criteria for Potentially Inappropriate Medication Use in Older Adults. Preventable hospitalizations were defined as hospitalizations for a potentially preventable condition.

Results: Compared with patients in the PCP only teams, patients in the team care practices with NPs or PAs received more guideline-recommended diabetes care (annual eye exam: adjusted odds ratio (aOR): 1.04 (95% CI: 1.00-1.08), 1.08 (95% CI: 1.03-1.13), and 1.10 (95% CI: 1.05-1.15), and HbA1C test: aOR: 1.11 (95% CI: 1.04-1.18), 1.11 (95% CI: 1.02-1.20), and 1.15 (95% CI: 1.06-1.25) for PCP/NP, PCP/NP/PA, and PCP/PA teams). Patients in the PCP/NP and the PCP/PA teams had a slightly higher likelihood of being prescribed high-risk medications (aOR: 1.03 (95% CI: 1.00-1.07), and 1.06 (95% CI: 1.02-1.11), respectively). The likelihood of preventable hospitalizations was similar among patients cared for by various types of practices.

Conclusion: The team care practices with NPs or PAs were associated with better adherence to clinical practice guideline recommendations for diabetes compared to PCP only practices. Both practices had similar outcomes. Further efforts are needed to explore new and cost-effective team-based care delivery models that improve process, outcomes, and continuity of care, as well as patient care experiences.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0241516PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7644045PMC
December 2020

Trends in Positive BRCA Test Results Among Older Women in the United States, 2008-2018.

JAMA Netw Open 2020 11 2;3(11):e2024358. Epub 2020 Nov 2.

Department of Obstetrics and Gynecology, The University of Texas Medical Branch at Galveston, Galveston.

Importance: Genetic testing for BRCA1/2 pathogenic variants has been used for targeted, individualized cancer prevention and treatment. A positive BRCA test result indicates a higher risk for developing BRCA-related cancers. During the past decade, testing criteria have loosened. The impact of these loosened criteria on BRCA testing in older women has not previously been studied.

Objective: To assess whether the rate of positive BRCA test results changed between 2008 and 2018 among older women in the United States.

Design, Setting, And Participants: This cross-sectional study used a 10% random sample of women 65 years of age or older from Optum's deidentified Integrated Claims-Clinical data set (2008-2018), a large national electronic health record data set. A total of 5533 women with BRCA test results from January 1, 2008, to March 31, 2018, were evaluated.

Main Outcomes And Measures: Annual percentage change in positive BRCA test results was evaluated. Multivariable logistic regression models were used to assess the association between positive test results and race/ethnicity, region of residence, income, educational level, and personal history of breast or ovarian cancer.

Results: Of 5533 women 65 years of age or older (mean age, 68.1 years [95% CI, 67.9-68.4 years]) who underwent BRCA testing from 2008 to 2018, most (4679 [84.6%]) were non-Hispanic White women, and 1915 (34.6%) resided in the Midwest. Positive BRCA test results decreased from 85.7% (36 of 42) in 2008 to 55.6% (140 of 252) in 2018 (annual percentage change, -2.55; 95% CI, -3.45 to -1.64). Among patients with breast or ovarian cancer, positive test results decreased from 83.3% (20 of 24) in 2008 to 61.6% (61 of 99) in 2018, while among women without breast or ovarian cancer, positive test results decreased from 87.5% (21 of 24) in 2008 to 48.4% (74 of 153) in 2018 (annual percentage change, -3.17 vs -2.49; P = .29). Women with positive test results were more likely to be non-Hispanic Black women, to live in the West or South, to live in areas with a low percentage of college graduates, or to not have a personal history of breast or ovarian cancer.

Conclusions And Relevance: This study suggests that there was a significantly decreasing rate of positive BRCA test results among women 65 years of age or older. Socioeconomic and regional disparities in testing use remain an issue.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1001/jamanetworkopen.2020.24358DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7645697PMC
November 2020

The Impact of Substance Use Disorder on COVID-19 Outcomes.

Psychiatr Serv 2021 05 3;72(5):578-581. Epub 2020 Nov 3.

Department of Preventive Medicine and Population Health (all authors), and Department of Internal Medicine (Kuo, Raji), University of Texas Medical Branch, Galveston.

Objective: The goal of this study was to examine the impact of substance use disorder on the risk of hospitalization, complications, and mortality among adult patients diagnosed as having COVID-19.

Methods: The authors conducted a propensity score (PS)-matched double-cohort study (N=5,562 in each cohort) with data from the TriNetX Research Network database to identify 54,529 adult patients (≥18 years) diagnosed as having COVID-19 between February 20 and June 30, 2020.

Results: Primary analysis (PS matched on demographic characteristics and presence of diabetes and obesity) showed that substance use disorder was associated with an increased risk of hospitalization (odds ratio [OR]=1.84, 95% confidence interval [CI]=1.69-2.01), ventilator use (OR=1.45, 95% CI=1.22-1.72), and mortality (OR=1.30, 95% CI=1.08-1.56).

Conclusions: The findings suggest that COVID-19 patients with substance use disorders are at increased risk for adverse outcomes. The attenuation of ORs in the model that matched for chronic respiratory and cardiovascular diseases associated with substance abuse suggests that the observed risks may be partially mediated by these conditions.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1176/appi.ps.202000534DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8089118PMC
May 2021

Patient Education on Opioid Storage, Security, and Disposal of Opioids: Should the Approach Differ in Rural and Urban Settings?

Tex J Health Syst Pharm 2020 ;19(1):46-51

Department of Preventive Medicine & Population Health, Office of Biostatistics, The University of Texas Medical Branch, Galveston, Texas.

Purpose: The opioid crisis is devastating rural America, but findings of opioid utilization vary among previous studies. Previous studies were focused on misuse behaviors or overdose issues. This study will focus on the number of pills and prescriptions that rural and urban adults received.

Methods: Using the adult data of the 2011-2016 Medical Expenditure Panel Survey, we compared rural-urban differences in likelihood of using opioids and actual utilization. Multivariate models were further adjusted for predisposing, enabling and need factors.

Results: During 2011-2016, opioid utilization decreased in both urban and rural areas. However, rural adults were still more likely to have a prescription, and among users, rural adult prescription pill count was higher than urban counterparts. The rural-urban difference was not significant after adjusting for covariates, indicating that personal and contextual characteristics account for more variations in utilization than rurality.

Conclusions: Strategies to improve pain management without causing opioid addiction and overdose deaths are imperative. The findings of unadjusted analyses suggest: (1) providing counseling to teach rural adults to store opioids in a locked container, not share medication with others and safely dispose of unused pills; (2) reinforcing the mail-back program or giving patients a specially-designed package to neutralize the drugs; and (3) if a community-based drug-disposal program is not available, educating to remove labeling from the bottle, mix the drugs with an unpleasant substance, and place the drugs and unpleasant substance in the garbage separate from the bottle. The findings of adjusted analyses indicate that another study will be helpful to explore the associations between personal characteristics and opioid utilization in depth.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7591146PMC
January 2020

How High-Risk Comorbidities Co-Occur in Readmitted Patients With Hip Fracture: Big Data Visual Analytical Approach.

JMIR Med Inform 2020 Oct 26;8(10):e13567. Epub 2020 Oct 26.

Department of Rehabilitation Sciences, University of Texas Medical Branch, Galveston, TX, United States.

Background: When older adult patients with hip fracture (HFx) have unplanned hospital readmissions within 30 days of discharge, it doubles their 1-year mortality, resulting in substantial personal and financial burdens. Although such unplanned readmissions are predominantly caused by reasons not related to HFx surgery, few studies have focused on how pre-existing high-risk comorbidities co-occur within and across subgroups of patients with HFx.

Objective: This study aims to use a combination of supervised and unsupervised visual analytical methods to (1) obtain an integrated understanding of comorbidity risk, comorbidity co-occurrence, and patient subgroups, and (2) enable a team of clinical and methodological stakeholders to infer the processes that precipitate unplanned hospital readmission, with the goal of designing targeted interventions.

Methods: We extracted a training data set consisting of 16,886 patients (8443 readmitted patients with HFx and 8443 matched controls) and a replication data set consisting of 16,222 patients (8111 readmitted patients with HFx and 8111 matched controls) from the 2010 and 2009 Medicare database, respectively. The analyses consisted of a supervised combinatorial analysis to identify and replicate combinations of comorbidities that conferred significant risk for readmission, an unsupervised bipartite network analysis to identify and replicate how high-risk comorbidity combinations co-occur across readmitted patients with HFx, and an integrated visualization and analysis of comorbidity risk, comorbidity co-occurrence, and patient subgroups to enable clinician stakeholders to infer the processes that precipitate readmission in patient subgroups and to propose targeted interventions.

Results: The analyses helped to identify (1) 11 comorbidity combinations that conferred significantly higher risk (ranging from P<.001 to P=.01) for a 30-day readmission, (2) 7 biclusters of patients and comorbidities with a significant bicluster modularity (P<.001; Medicare=0.440; random mean 0.383 [0.002]), indicating strong heterogeneity in the comorbidity profiles of readmitted patients, and (3) inter- and intracluster risk associations, which enabled clinician stakeholders to infer the processes involved in the exacerbation of specific combinations of comorbidities leading to readmission in patient subgroups.

Conclusions: The integrated analysis of risk, co-occurrence, and patient subgroups enabled the inference of processes that precipitate readmission, leading to a comorbidity exacerbation risk model for readmission after HFx. These results have direct implications for (1) the management of comorbidities targeted at high-risk subgroups of patients with the goal of pre-emptively reducing their risk of readmission and (2) the development of more accurate risk prediction models that incorporate information about patient subgroups.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.2196/13567DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7652691PMC
October 2020

Changing Population of Liver Transplant Recipients in the Era of Direct-acting Antiviral Therapy.

J Clin Transl Hepatol 2020 Sep 10;8(3):262-266. Epub 2020 Aug 10.

Department of Medicine, University of South Dakota Sanford School of Medicine, Sioux Falls, SD, USA.

With the availability of direct-acting antiviral (DAA) therapy for hepatitis C virus (HCV) infection and changing liver disease etiology for liver transplantation (LT), data on the changes in LT recipient population in the DAA era are scanty. The United Network for Organ Sharing (UNOS) registry (01/2007 to 06/2018) was used to develop a retrospective cohort of LT recipients for HCV, alcohol-associated liver disease (ALD), and non-alcoholic steatohepatitis (NASH). LT recipients in the DAA era (2013-2018) were compared with those in the pre-DAA era (2007-2012) era for recipient characteristics. Chi-square and analysis of variance were the statistical tests used for categorical and continuous variables, respectively. Of 40,309 LT recipients (21,110 HCV, 7586 NASH, and 11,713 ALD), the 21,790 in the DAA era (9432 HCV, 7240 ALD, and 5118 NASH) were more likely to be older, female, obese, diabetic, have acute-on-chronic liver failure with a higher model for end-stage liver disease score, receive grafts with a lower donor risk index, and have waited on the LT list for a shorter period compared with their pre-DAA era counterparts. Specific to ALD, LT recipients with alcohol hepatitis were more likely to be younger at the time of LT. Of 9895 LT recipients with hepatocellular carcinoma, recipients in the DAA era were observed to have a higher proportion of HCV (43% vs. 32%, <0.001), a lower proportion of ALD (9% vs. 12%, <0.001), and no change for NASH (13% vs. 13%, =0.9) compared with the pre-DAA era. Within the hepatocellular carcinoma population, LT recipients in the DAA era were older, diabetic, and waited on the LT list longer compared with their pre-DAA counterparts. Along with changing liver disease etiology in the DAA era, the LT recipient population demographics, comorbidities, liver disease severity, and graft quality are changing. These changes are relevant for future studies, immunosuppression, and post-transplant follow-up.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.14218/JCTH.2020.00032DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7562800PMC
September 2020