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Zhang DT, Onyebeke C, Nahid M, Balkan L, Musse M, Pinheiro LC, Sterling MR, Durant RW, Brown TM, Levitan EB, Safford MM, Goyal P. Social Determinants of Health and Cardiologist Involvement in the Care of Adults Hospitalized for Heart Failure. JAMA Netw Open 2023; 6:e2344070. [PMID: 37983029 PMCID: PMC10660170 DOI: 10.1001/jamanetworkopen.2023.44070] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2023] [Accepted: 10/10/2023] [Indexed: 11/21/2023] Open
Abstract
Importance Involvement of a cardiologist in the care of adults during a hospitalization for heart failure (HF) is associated with reduced rates of in-hospital mortality and hospital readmission. However, not all patients see a cardiologist when they are hospitalized for HF. Objective To determine whether social determinants of health (SDOH) are associated with cardiologist involvement in the management of adults hospitalized for HF. Design, Setting, and Participants This retrospective cohort study used data from the Reasons for Geographic and Racial Difference in Stroke (REGARDS) cohort. Participants included adults who experienced an adjudicated hospitalization for HF between 2009 and 2017 in all 48 contiguous states in the US. Data analysis was performed from November 2022 to January 2023. Exposures A total of 9 candidate SDOH, aligned with the Healthy People 2030 conceptual model, were examined: Black race, social isolation, social network and/or caregiver availability, educational attainment less than high school, annual household income less than $35 000, living in rural area, living in a zip code with high poverty, living in a Health Professional Shortage Area, and living in a state with poor public health infrastructure. Main Outcomes and Measures The primary outcome was cardiologist involvement, defined as involvement of a cardiologist as the primary responsible clinician or as a consultant. Bivariate associations between each SDOH and cardiologist involvement were examined using Poisson regression with robust SEs. Results The study included 1000 participants (median [IQR] age, 77.8 [71.5-84.0] years; 479 women [47.9%]; 414 Black individuals [41.4%]; and 492 of 876 with low income [56.2%]) hospitalized at 549 unique US hospitals. Low annual household income (<$35 000) was the only SDOH with a statistically significant association with cardiologist involvement (relative risk, 0.88; 95% CI, 0.82-0.95). In a multivariable analysis adjusting for age, race, sex, HF characteristics, comorbidities, and hospital characteristics, low income remained inversely associated with cardiologist involvement (relative risk, 0.89; 95% CI, 0.82-0.97). Conclusions and Relevance This cohort study found that adults with low household income were 11% less likely than adults with higher incomes to have a cardiologist involved in their care during a hospitalization for HF. These findings suggest that socioeconomic status may bias the care provided to patients hospitalized for HF.
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Affiliation(s)
- David T. Zhang
- Department of Medicine, Weill Cornell Medicine, New York, New York
| | | | - Musarrat Nahid
- Department of Medicine, Weill Cornell Medicine, New York, New York
| | - Lauren Balkan
- Department of Medicine, Weill Cornell Medicine, New York, New York
| | - Mahad Musse
- Department of Medicine, Weill Cornell Medicine, New York, New York
| | - Laura C. Pinheiro
- Department of Health Policy and Management, Weill Cornell Medicine, New York, New York
| | | | - Raegan W. Durant
- Department of Medicine, University of Alabama at Birmingham, Birmingham
| | - Todd M. Brown
- Department of Medicine, University of Alabama at Birmingham, Birmingham
| | - Emily B. Levitan
- Department of Epidemiology, University of Alabama at Birmingham, Birmingham
| | | | - Parag Goyal
- Department of Medicine, Weill Cornell Medicine, New York, New York
- Program for the Care and Study of the Aging Heart, Weill Cornell Medicine, New York, New York
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Kilaru AS, Friedman AB, Delgado MK. Considering the Whole Person in Hospital Admission Decisions for Older Adults in the Emergency Department. JAMA Intern Med 2023; 183:793-794. [PMID: 37307011 DOI: 10.1001/jamainternmed.2023.2155] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Affiliation(s)
- Austin S Kilaru
- Center for Emergency Care Policy and Research, Department of Emergency Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia
| | - Ari B Friedman
- Center for Emergency Care Policy and Research, Department of Emergency Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia
| | - Mucio Kit Delgado
- Center for Emergency Care Policy and Research, Department of Emergency Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia
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Rodriguez NJ, Zheng NS, Mezzacappa C, Canavan M, Laine L, Shung DL. Disparities in Access to Endoscopy for Patients With Upper Gastrointestinal Bleeding Presenting to Emergency Departments. Gastroenterology 2023; 164:1044-1046.e4. [PMID: 36228735 PMCID: PMC10083188 DOI: 10.1053/j.gastro.2022.10.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2022] [Revised: 09/26/2022] [Accepted: 10/02/2022] [Indexed: 12/02/2022]
Affiliation(s)
- Nicolette J. Rodriguez
- Brigham and Women’s Hospital, Boston, MA
- Dana-Farber Cancer Institute, Boston, MA
- Harvard Medical School, Boston, MA
| | | | | | | | - Loren Laine
- Yale School of Medicine, New Haven, CT
- Veterans Affairs Connecticut Healthcare System, West Haven, CT
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Michelson KA, McGarghan FLE, Patterson EE, Waltzman ML, Samuels-Kalow ME, Greco KF. Clinician factors associated with delayed diagnosis of appendicitis. Diagnosis (Berl) 2023; 10:183-186. [PMID: 36482753 PMCID: PMC10191871 DOI: 10.1515/dx-2022-0119] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2022] [Accepted: 11/22/2022] [Indexed: 12/14/2022]
Abstract
OBJECTIVES To evaluate the association of clinician demographics and practice patterns with delayed diagnosis of appendicitis. METHODS We included children with appendicitis at 13 regional emergency departments (EDs). We screened patients with a previous ED visit within 7 days for delayed diagnosis by chart review. We evaluated the association of clinician characteristics using logistic regression with random intercepts for site and clinician and delay as the outcome. RESULTS Among 7,452 children with appendicitis, 105 (1.4%) had delayed diagnosis. Clinicians in the lowest quartile of obtaining blood in their general practice were more likely to have delayed diagnosis (odds ratio 4.9 compared to highest quartile, 95% confidence interval 1.8, 13.8). Clinicians' imaging rates, specialty, sex, and experience were not associated with delayed diagnosis. CONCLUSIONS Clinicians who used more blood tests in their general practice had a lower risk of delayed diagnosis of appendicitis, possible evidence that lower risk tolerance has benefits.
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Affiliation(s)
- Kenneth A Michelson
- Division of Emergency Medicine, Boston Children’s Hospital, Boston, MA, United States
- Department of Pediatrics, South Shore Hospital, Weymouth, MA
| | - Finn L E McGarghan
- Division of Emergency Medicine, Boston Children’s Hospital, Boston, MA, United States
| | - Emma E Patterson
- Division of Emergency Medicine, Boston Children’s Hospital, Boston, MA, United States
| | - Mark L Waltzman
- Division of Emergency Medicine, Boston Children’s Hospital, Boston, MA, United States
- Department of Pediatrics, South Shore Hospital, Weymouth, MA
| | | | - Kimberly F Greco
- Institutional Centers for Clinical and Translational Research, Boston Children’s Hospital, Boston, MA, United States
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Zhang DT, Onyebeke C, Nahid M, Balkan L, Musse M, Pinheiro LC, Sterling MR, Durant RW, Brown TM, Levitan EB, Safford MM, Goyal P. Social Determinants of Health and Cardiologist Involvement in the Care of Adults Hospitalized for Heart Failure. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2023:2023.03.23.23287671. [PMID: 36993687 PMCID: PMC10055565 DOI: 10.1101/2023.03.23.23287671] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 06/19/2023]
Abstract
Introduction The involvement of a cardiologist in the care of adults during a hospitalization for heart failure (HF) is associated with reduced rates of in-hospital mortality and hospital readmission. However, not all patients see a cardiologist when they are hospitalized for HF. Since reasons for this are not entirely clear, we sought to determine whether social determinants of health (SDOH) are associated with cardiologist involvement in the management of adults hospitalized for HF. We hypothesized that SDOH would be inversely associated with cardiologist involvement in the care of adults hospitalized for HF. Methods We included adult participants from the national REasons for Geographic And Racial Difference in Stroke (REGARDS) cohort, who experienced an adjudicated hospitalization for HF between 2009 and 2017. We excluded participants who were hospitalized at institutions that lacked cardiology services (n=246). We examined nine candidate SDOH, which align with the Healthy People 2030 conceptual model: Black race, social isolation (0-1 visits from a family or friend in the past month), social network/caregiver availability (having someone to care for them if ill), educational attainment < high school, annual household income < $35,000, living in rural areas, living in a zip code with high poverty, living in a Health Professional Shortage Area, and residing in a state with poor public health infrastructure. The primary outcome was cardiologist involvement, a binary variable which was defined as involvement of a cardiologist as the primary responsible clinician or as a consultant, collected via chart review. We examined associations between each SDOH and cardiologist involvement using Poisson regression with robust standard errors. Candidate SDOH with statistically significant associations (p<0.10) were retained for multivariable analysis. Potential confounders/covariates for the multivariable analysis included age, race, sex, HF characteristics, comorbidities, and hospital characteristics. Results We examined 876 participants hospitalized at 549 unique US hospitals. The median age was 77.5 years (IQR 71.0-83.7), 45.9% were female, 41.4% were Black, and 56.2% had low income. Low household income (<$35,000/year) was the only SDOH that had a statistically significant association with cardiologist involvement in a bivariate analysis (RR: 0.88 [95% CI: 0.82-0.95]). After adjusting for potential confounders, low income remained inversely associated (RR: 0.89 [95% CI: 0.82-0.97]). Conclusions Adults with low household income were 11% less likely to have a cardiologist involved in their care during a hospitalization for HF. This suggests that socioeconomic status may implicitly bias the care provided to patients hospitalized for HF.
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Affiliation(s)
- David T. Zhang
- Department of Medicine, Weill Cornell Medicine, New York, NY
| | | | - Musarrat Nahid
- Division of General Internal Medicine, Department of Medicine, Weill Cornell Medicine, New York, NY
| | - Lauren Balkan
- Department of Medicine, Weill Cornell Medicine, New York, NY
| | - Mahad Musse
- Department of Medicine, Weill Cornell Medicine, New York, NY
| | - Laura C. Pinheiro
- Division of General Internal Medicine, Department of Medicine, Weill Cornell Medicine, New York, NY
| | - Madeline R. Sterling
- Division of General Internal Medicine, Department of Medicine, Weill Cornell Medicine, New York, NY
| | - Raegan W. Durant
- Division of Preventive Medicine, Department of Medicine, University of Alabama at Birmingham, Birmingham, AL
| | - Todd M. Brown
- Division of Cardiovascular Disease, Department of Medicine, University of Alabama at Birmingham, Birmingham, AL
| | - Emily B. Levitan
- Department of Epidemiology, University of Alabama at Birmingham, Birmingham, AL
| | | | - Parag Goyal
- Division of General Internal Medicine, Department of Medicine, Weill Cornell Medicine, New York, NY
- Division of Cardiology, Department of Medicine, Weill Cornell Medicine, New York, NY
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O'Malley AJ, Landon BE, Zaborski LA, Roberts ET, Khidir HH, Smulowitz PB, McWilliams JM. Weak correlations in health services research: Weak relationships or common error? Health Serv Res 2022; 57:182-191. [PMID: 34585380 PMCID: PMC8763298 DOI: 10.1111/1475-6773.13882] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2020] [Revised: 08/19/2021] [Accepted: 09/12/2021] [Indexed: 02/03/2023] Open
Abstract
OBJECTIVE To examine whether the correlation between a provider's effect on one population of patients and the same provider's effect on another population is underestimated if the effects for each population are estimated separately as opposed to being jointly modeled as random effects, and to characterize how the impact of the estimation procedure varies with sample size. DATA SOURCES Medicare claims and enrollment data on emergency department (ED) visits, including patient characteristics, the patient's hospitalization status, and identification of the doctor responsible for the decision to hospitalize the patient. STUDY DESIGN We used a three-pronged investigation consisting of analytical derivation, simulation experiments, and analysis of administrative data to demonstrate the fallibility of stratified estimation. Under each investigation method, results are compared between the joint modeling approach to those based on stratified analyses. DATA COLLECTION/EXTRACTION METHODS We used data on ED visits from administrative claims from traditional (fee-for-service) Medicare from January 2012 through September 2015. PRINCIPAL FINDINGS The simulation analysis demonstrates that the joint modeling approach is generally close to unbiased, whereas the stratified approach can be severely biased in small samples, a consequence of joint modeling benefitting from bivariate shrinkage and the stratified approach being compromised by measurement error. In the administrative data analyses, the estimated correlation of doctor admission tendencies between female and male patients was estimated to be 0.98 under the joint model but only 0.38 using stratified estimation. The analogous correlations for White and non-White patients are 0.99 and 0.28 and for Medicaid dual-eligible and non-dual-eligible patients are 0.99 and 0.31, respectively. These results are consistent with the analytical derivations. CONCLUSIONS Joint modeling targets the parameter of primary interest. In the case of population correlations, it yields estimates that are substantially less biased and higher in magnitude than naive estimators that post-process the estimates obtained from stratified models.
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Affiliation(s)
- Alistair James O'Malley
- Department of Biomedical Data Science and The Dartmouth Institute for Health Policy and Clinical PracticeGeisel School of Medicine at DartmouthLebanonNew HampshireUSA
| | - Bruce E. Landon
- Department of Health Care PolicyHarvard Medical SchoolBostonMassachusettsUSA,Division of General MedicineBeth Israel Deaconess Medical CenterBostonMassachusettsUSA
| | | | - Eric T. Roberts
- Department of Health Policy and ManagementUniversity of PittsburghPittsburghPennsylvaniaUSA
| | - Hazar H. Khidir
- National Clinician Scholars ProgramYale University School of MedicineNew HavenConnecticutUSA
| | - Peter B. Smulowitz
- Department of Emergency MedicineUniversity of Massachusetts Medical SchoolWorcesterMassachusettsUSA,Emergency DepartmentMilford Regional Medical CenterMilfordMassachusettsUSA
| | - John Michael McWilliams
- Department of Health Care PolicyHarvard Medical SchoolBostonMassachusettsUSA,Department of Internal MedicineBrigham and Women's HospitalBostonMassachusettsUSA
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Egede LE, Walker RJ, Williams JS. Intersection of Structural Racism, Social Determinants of Health, and Implicit Bias With Emergency Physician Admission Tendencies. JAMA Netw Open 2021; 4:e2126375. [PMID: 34546376 PMCID: PMC8594614 DOI: 10.1001/jamanetworkopen.2021.26375] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Affiliation(s)
- Leonard E Egede
- Division of General Internal Medicine, Department of Medicine, Medical College of Wisconsin, Milwaukee
- Center for Advancing Population Science, Medical College of Wisconsin, Milwaukee
| | - Rebekah J Walker
- Division of General Internal Medicine, Department of Medicine, Medical College of Wisconsin, Milwaukee
- Center for Advancing Population Science, Medical College of Wisconsin, Milwaukee
| | - Joni S Williams
- Division of General Internal Medicine, Department of Medicine, Medical College of Wisconsin, Milwaukee
- Center for Advancing Population Science, Medical College of Wisconsin, Milwaukee
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