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Noureldin M, Rubenstein JH, Urias E, Berinstein JA, Cohen-Mekelburg S, Saini SD, Higgins PD, Waljee AK. Racial Disparity in Esophageal Squamous Cell Carcinoma Treatment and Survival in the United States. Am J Gastroenterol 2024; 119:830-836. [PMID: 37975573 DOI: 10.14309/ajg.0000000000002606] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2023] [Accepted: 11/07/2023] [Indexed: 11/19/2023]
Abstract
INTRODUCTION Esophageal squamous cell carcinoma (ESCC) has a higher incidence and prevalence than esophageal adenocarcinoma among Black individuals in the United States. Black individuals have lower ESCC survival. These racial disparities have not been thoroughly investigated. We examined the disparity in treatment and survival stratified by ESCC stage at diagnosis. METHODS The Surveillance, Epidemiology, and End Results database was queried to identify patients with ESCC between 2000 and 2019. The identified cohort was divided into subgroups by race. Patient and cancer characteristics, treatment received, and survival rates were compared across the racial subgroups. RESULTS A total of 23,768 patients with ESCC were identified. Compared with White individuals, Black individuals were younger and had more distant disease during diagnosis (distant disease: 26.7% vs 23.8%, P < 0.001). Black individuals had lower age-standardized 5-year survival for localized (survival % [95% confidence interval]: 19.3% [16-22.8] vs 27.6% [25.1-30.2]), regional (14.3% [12-16.7] vs 21.1% [19.6-22.7]), and distant (2.9% [1.9-4.1] vs 6.5% [5.5-7.5]) disease. Black individuals were less likely to receive chemotherapy (54.7% vs 57.5%, P = 0.001), radiation (58.5% vs 60.4%, P = 0.03), and surgery (11.4% vs 16.3%, P < 0.0001). DISCUSSION Black individuals with ESCC have a lower survival rate than White individuals. This could be related to presenting at a later stage but also disparities in which treatments they receive even among individuals with the same stage of disease. To what extent these disparities in receipt of treatment is due to structural racism, social determinants of health, implicit bias, or patient preferences deserves further study.
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Affiliation(s)
- Mohamed Noureldin
- Division of Gastroenterology, University of Michigan Medical School, Ann Arbor, Michigan, USA
| | - Joel H Rubenstein
- Division of Gastroenterology, University of Michigan Medical School, Ann Arbor, Michigan, USA
- Center for Clinical Management Research, LTC Charles S. Kettles Veterans Affairs Medical Center, Ann Arbor, Michigan, USA
- Cancer Control and Population Sciences Program, Rogel Cancer Center, University of Michigan Medical School, Ann Arbor, Michigan, USA
| | - Esteban Urias
- Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Jeffrey A Berinstein
- Division of Gastroenterology, University of Michigan Medical School, Ann Arbor, Michigan, USA
| | - Shirley Cohen-Mekelburg
- Division of Gastroenterology, University of Michigan Medical School, Ann Arbor, Michigan, USA
- Center for Clinical Management Research, LTC Charles S. Kettles Veterans Affairs Medical Center, Ann Arbor, Michigan, USA
| | - Sameer D Saini
- Division of Gastroenterology, University of Michigan Medical School, Ann Arbor, Michigan, USA
- Center for Clinical Management Research, LTC Charles S. Kettles Veterans Affairs Medical Center, Ann Arbor, Michigan, USA
| | - Peter D Higgins
- Division of Gastroenterology, University of Michigan Medical School, Ann Arbor, Michigan, USA
| | - Akbar K Waljee
- Division of Gastroenterology, University of Michigan Medical School, Ann Arbor, Michigan, USA
- Department of Learning Health Sciences, University of Michigan Medical School, Ann Arbor, Michigan, USA
- Center for Global Health Equity, University of Michigan, Ann Arbor, Michigan, USA
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Noureldin M, Rubenstein JH, Kenney B, Waljee AK. Re-evaluating early-onset OSCC in Africa: findings of minimal cumulative incidence. Gut 2024:gutjnl-2023-331687. [PMID: 38360071 DOI: 10.1136/gutjnl-2023-331687] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2023] [Accepted: 02/02/2024] [Indexed: 02/17/2024]
Affiliation(s)
- Mohamed Noureldin
- Division of Gastroenterology, University of Michigan, Ann Arbor, MI, USA
| | - Joel H Rubenstein
- Division of Gastroenterology, University of Michigan, Ann Arbor, MI, USA
- Center for Clinical Management Research, VA Ann Arbor Health Care System, Ann Arbor, MI, USA
- Cancer Control and Population Sciences Program, Rogel Cancer Center, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Brooke Kenney
- Department of Learning Health Sciences, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Akbar K Waljee
- Center for Clinical Management Research, VA Ann Arbor Health Care System, Ann Arbor, MI, USA
- Department of Learning Health Sciences, University of Michigan Medical School, Ann Arbor, MI, USA
- Center for Global Health Equity, University of Michigan, Ann Arbor, MI, USA
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Njoroge W, Maina R, Frank E, Atwoli L, Wu Z, Ngugi AK, Sen S, Wang J, Wong S, Baker JA, Weinheimer-Haus EM, Khakali L, Aballa A, Orwa J, Nyongesa MK, Shah J, Waljee AK, Abubakar A, Merali Z. Correction: Use of mobile technology to identify behavioral mechanisms linked to mental health outcomes in Kenya: protocol for development and validation of a predictive model. BMC Res Notes 2024; 17:72. [PMID: 38475887 DOI: 10.1186/s13104-024-06731-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/14/2024] Open
Affiliation(s)
- Willie Njoroge
- Brain and Mind Institute, Aga Khan University, Nairobi, Kenya
- Department of Psychology, Southwest University, Chongqing, China
| | - Rachel Maina
- Brain and Mind Institute, Aga Khan University, Nairobi, Kenya.
- Department of Methodology and Statistics, Tilburg University, Tilburg, The Netherlands.
| | - Elena Frank
- Michigan Neuroscience Institute, University of Michigan, Michigan, USA
| | - Lukoye Atwoli
- Brain and Mind Institute, Aga Khan University, Nairobi, Kenya
- Department of Medicine, Medical College East Africa, The Aga Khan University, Nairobi, Kenya
| | - Zhenke Wu
- Department of Biostatistics, University of Michigan, Ann Arbor, MI, USA
| | - Anthony K Ngugi
- Department of Population Health, Aga Khan University, Srijan Sen, Nairobi, Kenya
| | - Srijan Sen
- Brain and Mind Institute, Aga Khan University, Nairobi, Kenya
| | - JianLi Wang
- Department of Community Health and Epidemiology, Dalhousie University, Halifax, Canada
| | - Stephen Wong
- Computing and Data Innovation Office, Aga Khan University, Nairobi, Kenya
| | - Jessica A Baker
- Center for Global Health Equity, University of Michigan, Ann Arbor, MI, USA
- Department of Learning Health Sciences, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Eileen M Weinheimer-Haus
- Center for Global Health Equity, University of Michigan, Ann Arbor, MI, USA
- Department of Learning Health Sciences, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Linda Khakali
- Brain and Mind Institute, Aga Khan University, Nairobi, Kenya
- Department of Sociology, University of Nairobi, Nairobi, Kenya
| | - Andrew Aballa
- Brain and Mind Institute, Aga Khan University, Nairobi, Kenya
| | - James Orwa
- Department of Population Health, Aga Khan University, Srijan Sen, Nairobi, Kenya
| | - Moses K Nyongesa
- Institute for Human Development, Aga Khan University, Nairobi, Kenya
| | - Jasmit Shah
- Brain and Mind Institute, Aga Khan University, Nairobi, Kenya
| | - Akbar K Waljee
- Center for Global Health Equity, University of Michigan, Ann Arbor, MI, USA
- Department of Learning Health Sciences, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Amina Abubakar
- Institute for Human Development, Aga Khan University, Nairobi, Kenya
- Neurosciences Unit, Kenya Medical Research Institute?Wellcome TrustResearch Programme, Kilifi, Kenya
| | - Zul Merali
- Brain and Mind Institute, Aga Khan University, Nairobi, Kenya
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Siwo GH, Singal AG, Waljee AK. Pan-cancer molecular signatures connecting aspartate transaminase (AST) to cancer prognosis, metabolic and immune signatures. bioRxiv 2024:2024.03.01.582939. [PMID: 38496547 PMCID: PMC10942358 DOI: 10.1101/2024.03.01.582939] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/19/2024]
Abstract
Background Serum aspartate transaminase (sAST) level is used routinely in conjunction with other clinical assays to assess liver health and disease. Increasing evidence suggests that sAST is associated with all-cause mortality and has prognostic value in several cancers, including gastrointestinal and urothelial cancers. Here, we undertake a systems approach to unravel molecular connections between AST and cancer prognosis, metabolism, and immune signatures at the transcriptomic and proteomic levels. Methods We mined public gene expression data across multiple normal and cancerous tissues using the Genotype Tissue Expression (GTEX) resource and The Cancer Genome Atlas (TCGA) to assess the expression of genes encoding AST isoenzymes (GOT1 and GOT2) and their association with disease prognosis and immune infiltration signatures across multiple tumors. We examined the associations between AST and previously reported pan-cancer molecular subtypes characterized by distinct metabolic and immune signatures. We analyzed human protein-protein interaction networks for interactions between GOT1 and GOT2 with cancer-associated proteins. Using public databases and protein-protein interaction networks, we determined whether the subset of proteins that interact with AST (GOT1 and GOT2 interactomes) are enriched with proteins associated with specific diseases, miRNAs and transcription factors. Results We show that AST transcript isoforms (GOT1 and GOT2) are expressed across a wide range of normal tissues. AST isoforms are upregulated in tumors of the breast, lung, uterus, and thymus relative to normal tissues but downregulated in tumors of the liver, colon, brain, kidney and skeletal sarcomas. At the proteomic level, we find that the expression of AST is associated with distinct pan-cancer molecular subtypes with an enrichment of specific metabolic and immune signatures. Based on human protein-protein interaction data, AST physically interacts with multiple proteins involved in tumor initiation, suppression, progression, and treatment. We find enrichments in the AST interactomes for proteins associated with liver and lung cancer and dermatologic diseases. At the regulatory level, the GOT1 interactome is enriched with the targets of cancer-associated miRNAs, specifically mir34a - a promising cancer therapeutic, while the GOT2 interactome is enriched with proteins that interact with cancer-associated transcription factors. Conclusions Our findings suggest that perturbations in the levels of AST within specific tissues reflect pathophysiological changes beyond tissue damage and have implications for cancer metabolism, immune infiltration, prognosis, and treatment personalization.
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Affiliation(s)
| | - Amit G. Singal
- Department of Learning Health Sciences, University of Michigan Medical School, Ann Arbor, MI, USA
- Department of Internal Medicine, UT Southwestern Medical Center, Dallas TX
- Center for Global Health Equity, University of Michigan, Ann Arbor, MI, USA
| | - Akbar K. Waljee
- Department of Learning Health Sciences, University of Michigan Medical School, Ann Arbor, MI, USA
- Department of Internal Medicine, UT Southwestern Medical Center, Dallas TX
- Center for Global Health Equity, University of Michigan, Ann Arbor, MI, USA
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Cohen-Mekelburg S, Jordan A, Kenney B, Burgess HJ, Chang JW, Hu HM, Tapper E, Langa KM, Levine DA, Waljee AK. Loneliness and Depressive Symptoms Are High Among Older Adults With Digestive Disease and Associated With Lower Perceived Health. Clin Gastroenterol Hepatol 2024; 22:621-629.e2. [PMID: 37689253 DOI: 10.1016/j.cgh.2023.08.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2023] [Revised: 06/09/2023] [Accepted: 08/15/2023] [Indexed: 09/11/2023]
Abstract
BACKGROUND & AIMS Current approaches to managing digestive disease in older adults fail to consider the psychosocial factors contributing to a person's health. We aimed to compare the frequency of loneliness, depression, and social isolation in older adults with and without a digestive disease and to quantify their association with poor health. METHODS We conducted an analysis of Health and Retirement Study data from 2008 to 2016, a nationally representative panel study of participants 50 years and older and their spouses. Bivariate analyses examined differences in loneliness, depression, and social isolation among patients with and without a digestive disease. We also examined the relationship between these factors and health. RESULTS We identified 3979 (56.0%) respondents with and 3131 (44.0%) without a digestive disease. Overall, 60.4% and 55.6% of respondents with and without a digestive disease reported loneliness (P < .001), 12.7% and 7.5% reported severe depression (P < .001), and 8.9% and 8.7% reported social isolation (P = NS), respectively. After adjusting for covariates, those with a digestive disease were more likely to report poor or fair health than those without a digestive disease (odds ratio [OR], 1.25; 95% CI, 1.11-1.41). Among patients with a digestive disease, loneliness (OR, 1.43; 95% CI, 1.22-1.69) and moderate and severe depression (OR, 2.93; 95% CI, 2.48-3.47; and OR, 8.96; 95% CI, 6.91-11.63, respectively) were associated with greater odds of poor or fair health. CONCLUSIONS Older adults with a digestive disease were more likely than those without a digestive disease to endorse loneliness and moderate to severe depression and these conditions are associated with poor or fair health. Gastroenterologists should feel empowered to screen patients for depression and loneliness symptoms and establish care pathways for mental health treatment.
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Affiliation(s)
- Shirley Cohen-Mekelburg
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Michigan Medicine, Ann Arbor, Michigan; Veterans Affairs Center for Clinical Management Research, US Department of Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, Michigan.
| | - Ariel Jordan
- Department of Internal Medicine, Michigan Medicine, Ann Arbor, Michigan
| | - Brooke Kenney
- Department of Surgery, Michigan Medicine, University of Michigan, Ann Arbor, Michigan
| | - Helen J Burgess
- Department of Psychiatry, Michigan Medicine, University of Michigan, Ann Arbor, Michigan
| | - Joy W Chang
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Michigan Medicine, Ann Arbor, Michigan
| | - Hsou Mei Hu
- Department of Surgery, Michigan Medicine, University of Michigan, Ann Arbor, Michigan
| | - Elliot Tapper
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Michigan Medicine, Ann Arbor, Michigan
| | - Kenneth M Langa
- Division of General Medicine, Department of Internal Medicine, Michigan Medicine, Ann Arbor, Michigan
| | - Deborah A Levine
- Division of General Medicine, Department of Internal Medicine, Michigan Medicine, Ann Arbor, Michigan
| | - Akbar K Waljee
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Michigan Medicine, Ann Arbor, Michigan; Veterans Affairs Center for Clinical Management Research, US Department of Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, Michigan
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Noureldin M, Newman KL, Higgins PDR, Piette JD, Resnicow K, Louissaint J, Kenney B, Berinstein J, Waljee AK, Zhu J, Cohen-Mekelburg S. Profiles of Web-based Portal Users with Inflammatory Bowel Disease. Inflamm Bowel Dis 2024; 30:83-89. [PMID: 37071851 PMCID: PMC10769793 DOI: 10.1093/ibd/izad056] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2022] [Indexed: 04/20/2023]
Abstract
BACKGROUND Web-based portals can enhance communication between patients and providers to support IBD self-management and improve care. We aimed to identify portal use patterns of patients with inflammatory bowel disease (IBD) to inform future web portal-based interventions and portal design. METHODS Patients with IBD receiving care at the University of Michigan between 2012 and 2021 were identified. Meta-data from electronic logs of each patient's most recent year of portal use were abstracted. Portal engagement was characterized in terms of intensity (ie, frequency of use); comprehensiveness (ie, number of portal functions used); and duration (ie, quarters per year of portal use). We used k-means clustering, a machine-learning technique, to identify groupings of portal users defined in terms of engagement features. RESULTS We found 5605 patients with IBD who had accessed their portal account at least once. The average age was 41.2 years (SD 16.7), 3035 (54.2%) were female, and 2214 (39.5%) received immune-targeted therapies. We identified 3 patterns of portal engagement: (1) low intensity users (29.5%); (2) moderate intensity, comprehensive, and sustained users (63.3%); and (3) high intensity, comprehensive, sustained users (7.2%). Patients with more intense, comprehensive, and sustained use of the portal were older, female, with more comorbidities, and were more likely to receive immune-targeted therapies. CONCLUSION Understanding distinct patterns of portal use can inform portal-based interventions and portal design. Patient portals may be particularly helpful in delivering assistance to those with comorbidities and those receiving immune-targeted therapies-many of whom demonstrate more intense, comprehensive, and sustained portal use.
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Affiliation(s)
- Mohamed Noureldin
- Division of Gastroenterology and Hepatology, University of Michigan Medicine, Ann Arbor, MI, USA
| | - Kira L Newman
- Division of Gastroenterology and Hepatology, University of Michigan Medicine, Ann Arbor, MI, USA
| | - Peter D R Higgins
- Division of Gastroenterology and Hepatology, University of Michigan Medicine, Ann Arbor, MI, USA
| | - John D Piette
- Department of Health Behavior and Health Education, University of Michigan School of Public Health, Ann Arbor, MI, USA
- VA Center for Clinical Management Research, VA Ann Arbor Health care System, Ann Arbor, MI, USA
| | - Kenneth Resnicow
- Department of Health Behavior and Health Education, University of Michigan School of Public Health, Ann Arbor, MI, USA
| | - Jeremy Louissaint
- Division of Gastroenterology and Hepatology, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Brooke Kenney
- Division of Gastroenterology and Hepatology, University of Michigan Medicine, Ann Arbor, MI, USA
| | - Jeffrey Berinstein
- Division of Gastroenterology and Hepatology, University of Michigan Medicine, Ann Arbor, MI, USA
| | - Akbar K Waljee
- Division of Gastroenterology and Hepatology, University of Michigan Medicine, Ann Arbor, MI, USA
- VA Center for Clinical Management Research, VA Ann Arbor Health care System, Ann Arbor, MI, USA
| | - Ji Zhu
- Department of Statistics, University of Michigan, Ann Arbor, MI, USA
| | - Shirley Cohen-Mekelburg
- Division of Gastroenterology and Hepatology, University of Michigan Medicine, Ann Arbor, MI, USA
- VA Center for Clinical Management Research, VA Ann Arbor Health care System, Ann Arbor, MI, USA
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Berinstein EM, Sheehan JL, Jacob J, Steiner CA, Stidham RW, Shannon C, Bishu S, Levine J, Cohen-Mekelburg SA, Waljee AK, Higgins PDR, Berinstein JA. Correction to: Efficacy and Safety of Dual Targeted Therapy for Partially or Non‑responsive Inflammatory Bowel Disease: A Systematic Review of the Literature. Dig Dis Sci 2023; 68:4540. [PMID: 37891442 DOI: 10.1007/s10620-023-08130-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/29/2023]
Affiliation(s)
- Elliot M Berinstein
- Department of Medicine, Trinity Health Ann Arbor Hospital, Ypsilanti, MI, USA
| | - Jessica L Sheehan
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Michigan Medicine, 1500 E. Medical Center Drive, Ann Arbor, MI, 48109, USA
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, USA
| | - Janson Jacob
- Department of Internal Medicine, Michigan Medicine, Ann Arbor, MI, USA
| | - Calen A Steiner
- Division of Gastroenterology and Hepatology, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Ryan W Stidham
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Michigan Medicine, 1500 E. Medical Center Drive, Ann Arbor, MI, 48109, USA
- Department of Computational Medicine and Bioinformatics, University of Michigan, Ann Arbor, MI, USA
| | - Carol Shannon
- Taubman Health Sciences Library, University of Michigan, Ann Arbor, MI, USA
| | - Shrinivas Bishu
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Michigan Medicine, 1500 E. Medical Center Drive, Ann Arbor, MI, 48109, USA
| | - Jake Levine
- Department of Internal Medicine, Michigan Medicine, Ann Arbor, MI, USA
| | - Shirley A Cohen-Mekelburg
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Michigan Medicine, 1500 E. Medical Center Drive, Ann Arbor, MI, 48109, USA
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, USA
- VA Center for Clinical Management Research, VA Ann Arbor Health Care System, Ann Arbor, MI, USA
| | - Akbar K Waljee
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Michigan Medicine, 1500 E. Medical Center Drive, Ann Arbor, MI, 48109, USA
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, USA
- VA Center for Clinical Management Research, VA Ann Arbor Health Care System, Ann Arbor, MI, USA
- Department of Learning Health Sciences, University of Michigan, Ann Arbor, MI, USA
| | - Peter D R Higgins
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Michigan Medicine, 1500 E. Medical Center Drive, Ann Arbor, MI, 48109, USA
| | - Jeffrey A Berinstein
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Michigan Medicine, 1500 E. Medical Center Drive, Ann Arbor, MI, 48109, USA.
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, USA.
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Cohen-Mekelburg S, Kenney B, Waljee AK. Reply. Clin Gastroenterol Hepatol 2023:S1542-3565(23)00962-X. [PMID: 38043693 DOI: 10.1016/j.cgh.2023.11.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2023] [Accepted: 11/19/2023] [Indexed: 12/05/2023]
Affiliation(s)
- Shirley Cohen-Mekelburg
- Division of Gastroenterology and Hepatology, Michigan Medicine, Ann Arbor, Michigan; VA Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, Michigan
| | - Brooke Kenney
- Department of Surgery, Michigan Medicine, University of Michigan, Ann Arbor, Michigan
| | - Akbar K Waljee
- Division of Gastroenterology and Hepatology, Michigan Medicine, Ann Arbor, Michigan; VA Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, Michigan; Department of Learning Health Sciences, Michigan Medicine, Ann Arbor, Michigan
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Wallace BI, Tsai H, Lin P, Aasbjerg K, Wu AC, Tsai Y, Torp‐Pedersen C, Waljee AK, Yao T. Prevalence and prescribing patterns of oral corticosteroids in the United States, Taiwan, and Denmark, 2009-2018. Clin Transl Sci 2023; 16:2565-2576. [PMID: 37718472 PMCID: PMC10719491 DOI: 10.1111/cts.13649] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2023] [Revised: 09/04/2023] [Accepted: 09/09/2023] [Indexed: 09/19/2023] Open
Abstract
Oral corticosteroids (OCS) are commonly prescribed for acute, self-limited conditions, despite studies demonstrating toxicity. Studies evaluating longitudinal OCS prescribing in the general population are scarce and do not compare use across countries. This study investigated and compared OCS prescription patterns from 2009 to 2018 in the general populations of the United States, Taiwan, and Denmark. This international population-based longitudinal cohort study used nationwide claims databases (United States: Optum Clinformatics Data Mart; de-identified; Taiwan: National Health Insurance Research Database; and Denmark: National Prescription and Patient Registries/Danish National Patient Registry) to evaluate OCS prescribing. We classified annual OCS duration as short-term (1-29 days), medium-term (30-89 days), or long-term (≥90 days). Longitudinal change in annual prevalence of OCS use and physician prescribing patterns were reported. Among 54,630,437 participants, average annual percentage of overall OCS use was 6.8% in the United States, 17.5% in Taiwan, and 2.2% in Denmark during 2009-2018. Prevalence of OCS prescribing increased at an average annual rate of 0.1%-0.17%, mainly driven by short-term prescribing to healthy adults. One-quarter to one-fifth of OCS prescribing was associated with a diagnosis of respiratory infection. Family practice and internal medicine physicians were among the highest OCS prescribers across countries and durations. Age- and sex-stratified trends mirrored unstratified trends. This study provides real-world evidence of an ongoing steady increase in OCS use in the general populations of the United States, Taiwan, and Denmark. This increase is largely driven by short-term OCS prescribing to healthy adults, a practice previously viewed as safe but recently shown to incur substantial population-level risk.
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Affiliation(s)
- Beth I. Wallace
- University of MichiganAnn ArborMichiganUSA
- Center for Clinical Management ResearchLieutenant Colonel Charles S. Kettles VA Medical CenterAnn ArborMichiganUSA
- Institute for Healthcare Policy and InnovationAnn ArborMichiganUSA
| | - Hui‐Ju Tsai
- Institute of Population Health SciencesNational Health Research InstitutesZhunanTaiwan
- National Tsing‐Hua University College of Life ScienceHsinchuTaiwan
| | - Paul Lin
- Institute for Healthcare Policy and InnovationAnn ArborMichiganUSA
| | | | - Ann Chen Wu
- Harvard Medical SchoolBostonMassachusettsUSA
- Department of Pediatrics, Children's HospitalBostonMassachusettsUSA
| | - Yi‐Fen Tsai
- Institute of Population Health SciencesNational Health Research InstitutesZhunanTaiwan
| | - Christian Torp‐Pedersen
- Department of Clinical Investigation and Cardiology, Nordsjaellands HospitalHilleroedDenmark
- Department of Clinical Medicine, Faculty of Health and Medical SciencesUniversity of CopenhagenCopenhagenDenmark
| | - Akbar K. Waljee
- University of MichiganAnn ArborMichiganUSA
- Center for Clinical Management ResearchLieutenant Colonel Charles S. Kettles VA Medical CenterAnn ArborMichiganUSA
- Institute for Healthcare Policy and InnovationAnn ArborMichiganUSA
| | - Tsung‐Chieh Yao
- Division of Allergy, Asthma, and Rheumatology, Department of Pediatrics, Chang Gung Memorial HospitalTaoyuanTaiwan
- School of MedicineChang Gung University College of MedicineTaoyuanTaiwan
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Rubenstein JH, Fontaine S, MacDonald PW, Burns JA, Evans RR, Arasim ME, Chang JW, Firsht EM, Hawley ST, Saini SD, Wallner LP, Zhu J, Waljee AK. Predicting Incident Adenocarcinoma of the Esophagus or Gastric Cardia Using Machine Learning of Electronic Health Records. Gastroenterology 2023; 165:1420-1429.e10. [PMID: 37597631 PMCID: PMC11013733 DOI: 10.1053/j.gastro.2023.08.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2023] [Revised: 07/11/2023] [Accepted: 08/09/2023] [Indexed: 08/21/2023]
Abstract
BACKGROUND & AIMS Tools that can automatically predict incident esophageal adenocarcinoma (EAC) and gastric cardia adenocarcinoma (GCA) using electronic health records to guide screening decisions are needed. METHODS The Veterans Health Administration (VHA) Corporate Data Warehouse was accessed to identify Veterans with 1 or more encounters between 2005 and 2018. Patients diagnosed with EAC (n = 8430) or GCA (n = 2965) were identified in the VHA Central Cancer Registry and compared with 10,256,887 controls. Predictors included demographic characteristics, prescriptions, laboratory results, and diagnoses between 1 and 5 years before the index date. The Kettles Esophageal and Cardia Adenocarcinoma predictioN (K-ECAN) tool was developed and internally validated using simple random sampling imputation and extreme gradient boosting, a machine learning method. Training was performed in 50% of the data, preliminary validation in 25% of the data, and final testing in 25% of the data. RESULTS K-ECAN was well-calibrated and had better discrimination (area under the receiver operating characteristic curve [AuROC], 0.77) than previously validated models, such as the Nord-Trøndelag Health Study (AuROC, 0.68) and Kunzmann model (AuROC, 0.64), or published guidelines. Using only data from between 3 and 5 years before index diminished its accuracy slightly (AuROC, 0.75). Undersampling men to simulate a non-VHA population, AUCs of the Nord-Trøndelag Health Study and Kunzmann model improved, but K-ECAN was still the most accurate (AuROC, 0.85). Although gastroesophageal reflux disease was strongly associated with EAC, it contributed only a small proportion of gain in information for prediction. CONCLUSIONS K-ECAN is a novel, internally validated tool predicting incident EAC and GCA using electronic health records data. Further work is needed to validate K-ECAN outside VHA and to assess how best to implement it within electronic health records.
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Affiliation(s)
- Joel H Rubenstein
- Veterans Affairs Center for Clinical Management Research, Lieutenant Colonel Charles S. Kettles Veterans Affairs Medical Center, Ann Arbor, Michigan; Division of Gastroenterology, Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, Michigan; Rogel Cancer Center, University of Michigan Medical School, Ann Arbor, Michigan; Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, Michigan.
| | - Simon Fontaine
- Department of Statistics, University of Michigan College of Literature, Science, and Arts, Ann Arbor, Michigan
| | - Peter W MacDonald
- Department of Statistics, University of Michigan College of Literature, Science, and Arts, Ann Arbor, Michigan
| | - Jennifer A Burns
- Veterans Affairs Center for Clinical Management Research, Lieutenant Colonel Charles S. Kettles Veterans Affairs Medical Center, Ann Arbor, Michigan
| | - Richard R Evans
- Veterans Affairs Center for Clinical Management Research, Lieutenant Colonel Charles S. Kettles Veterans Affairs Medical Center, Ann Arbor, Michigan
| | - Maria E Arasim
- Veterans Affairs Center for Clinical Management Research, Lieutenant Colonel Charles S. Kettles Veterans Affairs Medical Center, Ann Arbor, Michigan
| | - Joy W Chang
- Division of Gastroenterology, Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, Michigan
| | - Elizabeth M Firsht
- Veterans Affairs Center for Clinical Management Research, Lieutenant Colonel Charles S. Kettles Veterans Affairs Medical Center, Ann Arbor, Michigan
| | - Sarah T Hawley
- Veterans Affairs Center for Clinical Management Research, Lieutenant Colonel Charles S. Kettles Veterans Affairs Medical Center, Ann Arbor, Michigan; Rogel Cancer Center, University of Michigan Medical School, Ann Arbor, Michigan; Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, Michigan; Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, Michigan
| | - Sameer D Saini
- Veterans Affairs Center for Clinical Management Research, Lieutenant Colonel Charles S. Kettles Veterans Affairs Medical Center, Ann Arbor, Michigan; Division of Gastroenterology, Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, Michigan; Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, Michigan
| | - Lauren P Wallner
- Rogel Cancer Center, University of Michigan Medical School, Ann Arbor, Michigan; Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, Michigan; Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, Michigan
| | - Ji Zhu
- Department of Statistics, University of Michigan College of Literature, Science, and Arts, Ann Arbor, Michigan
| | - Akbar K Waljee
- Veterans Affairs Center for Clinical Management Research, Lieutenant Colonel Charles S. Kettles Veterans Affairs Medical Center, Ann Arbor, Michigan; Division of Gastroenterology, Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, Michigan; Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, Michigan
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11
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Rego RT, Zhukov Y, Reneau KA, Pienta A, Rice KL, Brady P, Siwo GH, Wachira PW, Abubakar A, Kollman K, Waljee AK. Promoting data harmonization to evaluate vaccine hesitancy in LMICs: approach and applications. BMC Med Res Methodol 2023; 23:278. [PMID: 38001442 PMCID: PMC10668461 DOI: 10.1186/s12874-023-02088-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2022] [Accepted: 10/31/2023] [Indexed: 11/26/2023] Open
Abstract
BACKGROUND Factors influencing the health of populations are subjects of interdisciplinary study. However, datasets relevant to public health often lack interdisciplinary breath. It is difficult to combine data on health outcomes with datasets on potentially important contextual factors, like political violence or development, due to incompatible levels of geographic support; differing data formats and structures; differences in sampling procedures and wording; and the stability of temporal trends. We present a computational package to combine spatially misaligned datasets, and provide an illustrative analysis of multi-dimensional factors in health outcomes. METHODS We rely on a new software toolkit, Sub-National Geospatial Data Archive (SUNGEO), to combine data across disciplinary domains and demonstrate a use case on vaccine hesitancy in Low and Middle-Income Countries (LMICs). We use data from the World Bank's High Frequency Phone Surveys (HFPS) from Kenya, Indonesia, and Malawi. We curate and combine these surveys with data on political violence, elections, economic development, and other contextual factors, using SUNGEO. We then develop a stochastic model to analyze the integrated data and evaluate 1) the stability of vaccination preferences in all three countries over time, and 2) the association between local contextual factors and vaccination preferences. RESULTS In all three countries, vaccine-acceptance is more persistent than vaccine-hesitancy from round to round: the long-run probability of staying vaccine-acceptant (hesitant) was 0.96 (0.65) in Indonesia, 0.89 (0.21) in Kenya, and 0.76 (0.40) in Malawi. However, vaccine acceptance was significantly less durable in areas exposed to political violence, with percentage point differences (ppd) in vaccine acceptance of -10 (Indonesia), -5 (Kenya), and -64 (Malawi). In Indonesia and Kenya, although not Malawi, vaccine acceptance was also significantly less durable in locations without competitive elections (-19 and -6 ppd, respectively) and in locations with more limited transportation infrastructure (-11 and -8 ppd). CONCLUSION With SUNGEO, researchers can combine spatially misaligned and incompatible datasets. As an illustrative example, we find that vaccination hesitancy is correlated with political violence, electoral uncompetitiveness and limited access to public goods, consistent with past results that vaccination hesitancy is associated with government distrust.
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Affiliation(s)
- Ryan T Rego
- Center for Global Health Equity, Michigan Medicine, University of Michigan, Ann Arbor, MI, USA.
- Department of Epidemiology, School of Public Health, University of Michigan, Ann Arbor, MI, USA.
| | - Yuri Zhukov
- Center for Political Studies, Institute for Social Research, University of Michigan, Ann Arbor, MI, USA
- Edmund A Walsh School of Foreign Service, Georgetown University, Washington, DC, USA
| | - Kyrani A Reneau
- Inter-university Consortium for Political and Social Research, Institute for Social Research, University of Michigan, Ann Arbor, MI, USA
| | - Amy Pienta
- Inter-university Consortium for Political and Social Research, Institute for Social Research, University of Michigan, Ann Arbor, MI, USA
| | - Kristina L Rice
- Center for Global Health Equity, Michigan Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Patrick Brady
- Department of Learning Health Sciences, Michigan Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Geoffrey H Siwo
- Center for Global Health Equity, Michigan Medicine, University of Michigan, Ann Arbor, MI, USA
- Department of Learning Health Sciences, Michigan Medicine, University of Michigan, Ann Arbor, MI, USA
| | | | - Amina Abubakar
- Institute for Human Development, Aga Khan University, Nairobi, Kenya
| | - Ken Kollman
- Center for Political Studies, Institute for Social Research, University of Michigan, Ann Arbor, MI, USA
- Department of Political Science, College of Letters, Sciences, and Arts, University of Michigan, Ann Arbor, MI, USA
| | - Akbar K Waljee
- Center for Global Health Equity, Michigan Medicine, University of Michigan, Ann Arbor, MI, USA
- Department of Learning Health Sciences, Michigan Medicine, University of Michigan, Ann Arbor, MI, USA
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12
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Tsai HJ, Wallace BI, Waljee AK, Hong X, Chang SM, Tsai YF, Cheong ML, Wu AC, Yao TC. Association between antenatal corticosteroid treatment and severe adverse events in pregnant women. BMC Med 2023; 21:413. [PMID: 37907932 PMCID: PMC10617183 DOI: 10.1186/s12916-023-03125-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2023] [Accepted: 10/23/2023] [Indexed: 11/02/2023] Open
Abstract
BACKGROUND Antenatal corticosteroids are considered the standard of care for pregnant women at risk for preterm birth, but studies examining their potential risks are scarce. We aimed to estimate the associations of antenatal corticosteroids with three severe adverse events: sepsis, heart failure, and gastrointestinal bleeding, in pregnant women. METHODS Of 2,157,321 pregnant women, 52,119 at 24 weeks 0/7 days to 36 weeks 6/7 days of gestation were included in this self-controlled case series study during the study period of 2009-2018. We estimated incidence rates of three severe adverse events: sepsis, heart failure, and gastrointestinal bleeding. Conditional Poisson regression was used to calculate incidence rate ratios (IRRs) for comparing incidence rates of the adverse events in each post-treatment period compared to those during the baseline period among pregnant women exposed to a single course of antenatal corticosteroid treatment. RESULTS Among 52,119 eligible participants who received antenatal corticosteroid treatment, the estimated incidence rates per 1000 person-years were 0.76 (95% confidence interval (CI): 0.69-0.83) for sepsis, 0.31 (95% CI: 0.27-0.36) for heart failure, and 11.57 (95% CI: 11.27-11.87) for gastrointestinal bleeding. The IRRs at 5 ~ 60 days after administration of antenatal corticosteroids were 5.91 (95% CI: 3.10-11.30) for sepsis and 4.45 (95% CI: 2.63-7.55) for heart failure, and 1.26 (95% CI: 1.02-1.55) for gastrointestinal bleeding; and the IRRs for days 61 ~ 180 were 2.00 (95% CI: 1.01-3.96) for sepsis, 3.65 (95% CI: 2.14-6.22) for heart failure, and 1.81 (95% CI: 1.56-2.10) for gastrointestinal bleeding. CONCLUSIONS This nationwide population-based study suggests that a single course of antenatal corticosteroids is significantly associated with a 1.3- to 5.9-fold increased risk of sepsis, heart failure, and gastrointestinal bleeding in pregnant women. Maternal health considerations, including recommendations for adverse event monitoring, should be included in future guidelines for antenatal corticosteroid treatment.
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Affiliation(s)
- Hui-Ju Tsai
- Institute of Population Health Sciences, National Health Research Institutes, Zhunan, Taiwan
- National Tsing-Hua University, Hsinchu, Taiwan
| | - Beth I Wallace
- Center for Clinical Management Research, Lieutenant Colonel Charles S. Kettles VA Medical Center, Ann Arbor, MI, USA
- University of Michigan, Ann Arbor, MI, USA
- Institute for Healthcare Policy and Innovation, Ann Arbor, MI, USA
| | - Akbar K Waljee
- Center for Clinical Management Research, Lieutenant Colonel Charles S. Kettles VA Medical Center, Ann Arbor, MI, USA
- University of Michigan, Ann Arbor, MI, USA
- Institute for Healthcare Policy and Innovation, Ann Arbor, MI, USA
| | - Xiumei Hong
- Department of Population, Family and Reproductive Health, Center On Early Life Origins of Disease, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, USA
| | - Sheng-Mao Chang
- Department of Statistics, National Taipei University, Taipei, Taiwan
| | - Yi-Fen Tsai
- Institute of Population Health Sciences, National Health Research Institutes, Zhunan, Taiwan
| | - Mei-Leng Cheong
- National Tsing-Hua University, Hsinchu, Taiwan
- Department of Obstetrics and Gynecology, Cathay General Hospital, Taipei, Taiwan
| | | | - Tsung-Chieh Yao
- Division of Allergy, Asthma, and Rheumatology, Department of Pediatrics, Chang Gung Memorial Hospital, 5 Fu-Hsin Street, Kweishan, Taoyuan, 33305, Taiwan.
- School of Medicine, Chang Gung University College of Medicine, Taoyuan, Taiwan.
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13
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Njoroge W, Maina R, Frank E, Atwoli L, Wu Z, Ngugi AK, Sen S, Wang J, Wong S, Baker JA, Weinheimer-Haus EM, Khakali L, Aballa A, Orwa J, K Nyongesa M, Shah J, Waljee AK, Abubakar A, Merali Z. Use of mobile technology to identify behavioral mechanisms linked to mental health outcomes in Kenya: protocol for development and validation of a predictive model. BMC Res Notes 2023; 16:226. [PMID: 37735439 PMCID: PMC10515076 DOI: 10.1186/s13104-023-06498-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2023] [Accepted: 09/04/2023] [Indexed: 09/23/2023] Open
Abstract
OBJECTIVE This study proposes to identify and validate weighted sensor stream signatures that predict near-term risk of a major depressive episode and future mood among healthcare workers in Kenya. APPROACH The study will deploy a mobile application (app) platform and use novel data science analytic approaches (Artificial Intelligence and Machine Learning) to identifying predictors of mental health disorders among 500 randomly sampled healthcare workers from five healthcare facilities in Nairobi, Kenya. EXPECTATION This study will lay the basis for creating agile and scalable systems for rapid diagnostics that could inform precise interventions for mitigating depression and ensure a healthy, resilient healthcare workforce to develop sustainable economic growth in Kenya, East Africa, and ultimately neighboring countries in sub-Saharan Africa. This protocol paper provides an opportunity to share the planned study implementation methods and approaches. CONCLUSION A mobile technology platform that is scalable and can be used to understand and improve mental health outcomes is of critical importance.
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Affiliation(s)
- Willie Njoroge
- Brain and Mind Institute, Aga Khan University, Nairobi, Kenya
- Department of Psychology, Southwest University, Chongqing, China
| | - Rachel Maina
- Brain and Mind Institute, Aga Khan University, Nairobi, Kenya.
- Department of Methodology and Statistics, Tilburg University, Tilburg, The Netherlands.
| | - Elena Frank
- Michigan Neuroscience Institute, University of Michigan, Michigan, USA
| | - Lukoye Atwoli
- Brain and Mind Institute, Aga Khan University, Nairobi, Kenya
- Department of Medicine, Medical College East Africa, the Aga Khan University, Nairobi, Kenya
| | - Zhenke Wu
- Department of Biostatistics, University of Michigan, Ann Arbor, MI, USA
| | - Anthony K Ngugi
- Department of Population Health, Aga Khan University, Nairobi, Kenya
| | - Srijan Sen
- Brain and Mind Institute, Aga Khan University, Nairobi, Kenya
| | - JianLi Wang
- Department of Community Health and Epidemiology, Dalhousie University, Halifax, Canada
| | - Stephen Wong
- Computing and Data Innovation Office, Aga Khan University, Nairobi, Kenya
| | - Jessica A Baker
- Center for Global Health Equity, University of Michigan, Ann Arbor, MI, USA
- Department of Learning Health Sciences, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Eileen M Weinheimer-Haus
- Center for Global Health Equity, University of Michigan, Ann Arbor, MI, USA
- Department of Learning Health Sciences, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Linda Khakali
- Brain and Mind Institute, Aga Khan University, Nairobi, Kenya
- Department of Sociology, University of Nairobi, Nairobi, Kenya
| | - Andrew Aballa
- Brain and Mind Institute, Aga Khan University, Nairobi, Kenya
| | - James Orwa
- Department of Population Health, Aga Khan University, Nairobi, Kenya
| | - Moses K Nyongesa
- Institute for Human Development, Aga Khan University, Nairobi, Kenya
| | - Jasmit Shah
- Brain and Mind Institute, Aga Khan University, Nairobi, Kenya
| | - Akbar K Waljee
- Center for Global Health Equity, University of Michigan, Ann Arbor, MI, USA
- Department of Learning Health Sciences, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Amina Abubakar
- Institute for Human Development, Aga Khan University, Nairobi, Kenya
- Neurosciences Unit, Kenya Medical Research Institute-Wellcome Trust Research Programme, Kilifi, Kenya
| | - Zul Merali
- Brain and Mind Institute, Aga Khan University, Nairobi, Kenya
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14
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Cohen-Mekelburg S, Van T, Berinstein JA, Yu X, Costa DK, Wallace BI, Saini S, Admon AJ, Higgins PDR, Zhu J, Waljee AK. Characteristics of Facilities With Early and Rapid Ustekinumab Adoption for Patients With Inflammatory Bowel Disease. Am J Gastroenterol 2023; 118:1688-1692. [PMID: 37104671 PMCID: PMC10524501 DOI: 10.14309/ajg.0000000000002304] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2022] [Accepted: 03/23/2023] [Indexed: 04/29/2023]
Abstract
INTRODUCTION To examine which facility characteristics, including teamwork, are associated with early or rapid inflammatory bowel disease-related ustekinumab adoption. METHODS We examined the association between ustekinumab adoption and the characteristics of 130 Veterans Affairs facilities. RESULTS Mean ustekinumab adoption increased by 3.9% from 2016 to 2018 and was higher in urban compared with rural facilities (β = 0.03, P = 0.033) and among facilities with more teamwork (β = 0.11, P = 0.041). Compared with nonearly adopters, early adopters were more likely be high-volume facilities (46% vs 19%, P = 0.001). DISCUSSION Facility variation in medication adoption provides an opportunity for improving inflammatory bowel disease care through targeted dissemination strategies to improve medication uptake.
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Affiliation(s)
- Shirley Cohen-Mekelburg
- VA Center for Clinical Management Research, LTC Charles Kettles VA Medical Center, Ann Arbor, MI
- Gastroenterology Service, LTC Charles Kettles VA Medical Center, Ann Arbor, MI
- Division of Gastroenterology & Hepatology, University of Michigan Medicine, Ann Arbor, MI
| | - Tony Van
- VA Center for Clinical Management Research, LTC Charles Kettles VA Medical Center, Ann Arbor, MI
| | - Jeffrey A. Berinstein
- Division of Gastroenterology & Hepatology, University of Michigan Medicine, Ann Arbor, MI
| | - Xianshi Yu
- Department of Statistics, University of Michigan Medicine, Ann Arbor, MI
| | - Deena Kelly Costa
- School of Nursing, Yale University, New Haven, CT
- Section on Pulmonary, Critical Care & Sleep Medicine, Department of Internal Medicine, Yale University, New Haven, CT
| | - Beth I. Wallace
- VA Center for Clinical Management Research, LTC Charles Kettles VA Medical Center, Ann Arbor, MI
- Division of Rheumatology, Department of Internal Medicine, University of Michigan Medicine, Ann Arbor, MI
- Rheumatology Service, LTC Charles Kettles VA Medical Center, Ann Arbor, MI
| | - Sameer Saini
- VA Center for Clinical Management Research, LTC Charles Kettles VA Medical Center, Ann Arbor, MI
- Gastroenterology Service, LTC Charles Kettles VA Medical Center, Ann Arbor, MI
- Division of Gastroenterology & Hepatology, University of Michigan Medicine, Ann Arbor, MI
| | - Andrew J. Admon
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Michigan Medicine, Ann Arbor, MI
- Pulmonary Service, LTC Charles Kettles VA Medical Center, Ann Arbor, MI
| | - Peter D. R. Higgins
- Division of Gastroenterology & Hepatology, University of Michigan Medicine, Ann Arbor, MI
| | - Ji Zhu
- Department of Statistics, University of Michigan Medicine, Ann Arbor, MI
| | - Akbar K. Waljee
- VA Center for Clinical Management Research, LTC Charles Kettles VA Medical Center, Ann Arbor, MI
- Gastroenterology Service, LTC Charles Kettles VA Medical Center, Ann Arbor, MI
- Division of Gastroenterology & Hepatology, University of Michigan Medicine, Ann Arbor, MI
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Cohen-Mekelburg S, Van T, Wallace BI, Berinstein J, Yu X, Lewis J, Hou J, Dominitz JA, Waljee AK. Response to Squirell et al. Am J Gastroenterol 2023; 118:1462-1463. [PMID: 37534810 DOI: 10.14309/ajg.0000000000002276] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/04/2023]
Affiliation(s)
- Shirley Cohen-Mekelburg
- Division of Gastroenterology and Hepatology, University of Michigan Medicine, Ann Arbor, Michigan, USA
- VA Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, Michigan, USA
| | - Tony Van
- VA Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, Michigan, USA
| | - Beth I Wallace
- VA Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, Michigan, USA
- Division of Rheumatology, University of Michigan Medicine, Ann Arbor, Michigan, USA
| | - Jeffrey Berinstein
- Division of Gastroenterology and Hepatology, University of Michigan Medicine, Ann Arbor, Michigan, USA
| | - Xianshi Yu
- Department of Statistics, University of Michigan, Ann Arbor, Michigan, USA
| | - James Lewis
- Division of Gastroenterology and Hepatology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Jason Hou
- Division of Gastroenterology and Hepatology, Baylor College of Medicine, Houston, Texas, USA
- VA Houston Healthcare System, Houston, Texas, USA
| | - Jason A Dominitz
- VA Puget Sound Healthcare System, Seattle, Washington, USA
- Division of Gastroenterology and Hepatology, University of Washington, Seattle, Washington, USA
| | - Akbar K Waljee
- Division of Gastroenterology and Hepatology, University of Michigan Medicine, Ann Arbor, Michigan, USA
- VA Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, Michigan, USA
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Patel J, Noureldin M, Fakhouri D, Farraye FA, Kovar-Gough I, Warren B, Waljee AK, Piper MS. Interventions Increase Vaccination Rates in Inflammatory Bowel Disease and Rheumatoid Arthritis: A Systematic Review and Meta-Analysis. Dig Dis Sci 2023; 68:2921-2935. [PMID: 37024741 PMCID: PMC10079156 DOI: 10.1007/s10620-023-07903-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2022] [Accepted: 02/24/2023] [Indexed: 04/08/2023]
Abstract
BACKGROUND Patients with immune-mediated conditions such as IBD and RA are at risk for vaccine-preventable infections. Despite guideline recommendations, prior studies have shown suboptimal vaccination rates. AIM We conducted a systematic review and meta-analysis to compare the different interventions intended to increase vaccination rates. METHODS A systematic search was conducted of MEDLINE/PubMed, Embase, CINAHL, and Cochrane Library up to 2020 for studies with interventions intended to increase vaccination rates. We performed a random-effects meta-analysis to generate pooled odds ratios (ORs) to assess all interventions against no interventions. Our primary outcome was pneumococcal vaccination (PCV) rate. RESULTS Our review found 8580 articles, for which 15 IBD and 8 RA articles met the inclusion criteria; 21 articles were included in the analysis. PCV was the predominant vaccination (91%). In our analysis of patients with IBD, almost all interventions (patient-oriented, physician-oriented, or barrier-oriented) increased PCV uptake [OR, 4.74; 95% CI, 2.44-6.56, I2 = 90%] compared to no intervention. The greatest effect was seen in barrier-oriented studies [OR, 12.68; 95% CI, 2.21-72.62, I2 = 92%]. For RA data, all interventions had increased PCV uptake compared to no interventions (OR 2.74; 95% CI, 1.80-4.17, I2 = 95%). CONCLUSION Our data suggest that many different interventions can increase PCV rates. It appears that barrier-oriented interventions may have the greatest positive effect on increasing PCV uptake. However, clinicians should be encouraged to implement measures best suited to their practice. Future high-quality randomized controlled trials are needed to determine the best approach to optimize vaccination rates.
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Affiliation(s)
- Jalpa Patel
- Division of Gastroenterology, Ascension Providence-Providence Park Hospital, Michigan State University College of Human Medicine, 16001 W. Nine Mile Road, Southfield, MI 48310 USA
| | - Mohamed Noureldin
- Division of Gastroenterology and Hepatology, University of Michigan Ann Arbor, Ann Arbor, MI 48109 USA
| | - Dina Fakhouri
- Division of Internal Medicine, Ascension Macomb-Oakland Macomb Campus, 1800 Twelve Mile Road, Warren, MI 48093 USA
| | - Francis A. Farraye
- Division of Gastroenterology and Hepatology, Mayo Clinic Inflammatory Bowel Disease Center, Jacksonville, FL 32224 USA
| | | | - Bradley Warren
- Division of Gastroenterology, Ascension Providence-Providence Park Hospital, Michigan State University College of Human Medicine, 16001 W. Nine Mile Road, Southfield, MI 48310 USA
| | - Akbar K. Waljee
- Division of Gastroenterology and Hepatology, University of Michigan Ann Arbor, Ann Arbor, MI 48109 USA
| | - Marc S. Piper
- Division of Gastroenterology, Ascension Providence-Providence Park Hospital, Michigan State University College of Human Medicine, 16001 W. Nine Mile Road, Southfield, MI 48310 USA
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Sheehan JL, Greene-Higgs L, Swanson L, Higgins PD, Krein SL, Waljee AK, Saini SD, Berinstein JA, Mellinger JL, Piette JD, Resnicow K, Cohen-Mekelburg S. Self-Efficacy and the Impact of Inflammatory Bowel Disease on Patients' Daily Lives. Clin Transl Gastroenterol 2023; 14:e00577. [PMID: 36881812 PMCID: PMC10299768 DOI: 10.14309/ctg.0000000000000577] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2022] [Accepted: 02/24/2023] [Indexed: 03/09/2023] Open
Abstract
INTRODUCTION Self-efficacy, i.e., the confidence in one's capacity to perform a behavior, is crucial to the development of inflammatory bowel disease (IBD) self-management skills. We aimed to measure IBD self-efficacy and the relationship between self-efficacy and the patient-reported impact of IBD on daily life. METHODS We surveyed patients with IBD from a single academic center using the IBD Self-Efficacy Scale (IBD-SES) and patient-reported outcome (PRO) measures. The IBD-SES assesses 4 IBD domains: patients' confidence in managing stress and emotions, symptoms and disease, medical care, and remission. IBD PROs evaluate daily life impact, coping strategies, emotional impact, and systemic symptoms. We examined the association between IBD-SES domains with the lowest scores and IBD daily life impact. RESULTS A total of 160 patients completed the survey. Domain scores on the IBD-SES were lowest for managing stress and emotions (mean 6.76, SD 1.86) and symptoms and disease (mean 6.71, SD 2.12) on a 1-10 scale. Controlling for age, sex, IBD type, disease activity, moderate-to-severe disease, depression and anxiety, a higher confidence in managing stress and emotions (β -0.12, 95% confidence interval -0.20 to -0.05, P = 0.001), and managing symptoms and disease (β -0.28, 95% confidence interval -0.35 to -0.20, P < 0.001) were each associated with lower IBD daily life impact. DISCUSSION Patients with IBD report low confidence in managing stress and emotion and managing symptoms and disease. Higher self-efficacy in these domains was associated with lower IBD daily life impact. Self-management tools that promote self-efficacy in managing these domains have the potential to reduce IBD's daily life impact.
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Affiliation(s)
- Jessica L. Sheehan
- Department of Internal Medicine, Michigan Medicine, Ann Arbor, Michigan, USA
- Department of Internal Medicine, Division of Gastroenterology and Hepatology, Michigan Medicine, Ann Arbor, Michigan, USA
| | - LaVana Greene-Higgs
- Department of Internal Medicine, Michigan Medicine, Ann Arbor, Michigan, USA
| | - Linnea Swanson
- Department of Internal Medicine, Michigan Medicine, Ann Arbor, Michigan, USA
| | - Peter D.R. Higgins
- Department of Internal Medicine, Division of Gastroenterology and Hepatology, Michigan Medicine, Ann Arbor, Michigan, USA
| | - Sarah L. Krein
- Department of Internal Medicine, Michigan Medicine, Ann Arbor, Michigan, USA
- VA Center for Clinical Management Research, VA Ann Arbor Health Care System, Ann Arbor, Michigan, USA
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, Michigan, USA
| | - Akbar K. Waljee
- Department of Internal Medicine, Division of Gastroenterology and Hepatology, Michigan Medicine, Ann Arbor, Michigan, USA
- VA Center for Clinical Management Research, VA Ann Arbor Health Care System, Ann Arbor, Michigan, USA
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, Michigan, USA
| | - Sameer D. Saini
- Department of Internal Medicine, Division of Gastroenterology and Hepatology, Michigan Medicine, Ann Arbor, Michigan, USA
- VA Center for Clinical Management Research, VA Ann Arbor Health Care System, Ann Arbor, Michigan, USA
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, Michigan, USA
| | - Jeffrey A. Berinstein
- Department of Internal Medicine, Division of Gastroenterology and Hepatology, Michigan Medicine, Ann Arbor, Michigan, USA
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, Michigan, USA
| | - Jessica L. Mellinger
- Department of Internal Medicine, Division of Gastroenterology and Hepatology, Michigan Medicine, Ann Arbor, Michigan, USA
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, Michigan, USA
- Department of Psychiatry, Michigan Medicine, Ann Arbor, Michigan, USA
| | - John D. Piette
- VA Center for Clinical Management Research, VA Ann Arbor Health Care System, Ann Arbor, Michigan, USA
- University of Michigan School of Public Health, Department of Health Behavior and Health Education, Ann Arbor, Michigan, USA
| | - Ken Resnicow
- University of Michigan School of Public Health, Department of Health Behavior and Health Education, Ann Arbor, Michigan, USA
| | - Shirley Cohen-Mekelburg
- Department of Internal Medicine, Division of Gastroenterology and Hepatology, Michigan Medicine, Ann Arbor, Michigan, USA
- VA Center for Clinical Management Research, VA Ann Arbor Health Care System, Ann Arbor, Michigan, USA
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, Michigan, USA
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Berinstein EM, Sheehan JL, Jacob J, Steiner CA, Stidham RW, Shannon C, Bishu S, Levine J, Cohen-Mekelburg SA, Waljee AK, Higgins PDR, Berinstein JA. Efficacy and Safety of Dual Targeted Therapy for Partially or Non-responsive Inflammatory Bowel Disease: A Systematic Review of the Literature. Dig Dis Sci 2023; 68:2604-2623. [PMID: 36807832 PMCID: PMC9942632 DOI: 10.1007/s10620-023-07837-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2021] [Accepted: 01/13/2023] [Indexed: 02/23/2023]
Abstract
BACKGROUND Dual targeted therapy (DTT) has emerged as an attractive therapeutic option for select patients with active inflammatory bowel disease (IBD) who are unable to achieve remission with biologic or small molecule monotherapy. We conducted a systematic review of specific DTT combinations in patients with IBD. METHODS We conducted a systematic search of MEDLINE, EMBASE, Scopus, CINAHL Complete, Web of Science Core Collection, and Cochrane Library to identify articles related to the use of DTT for the treatment of Crohn Disease (CD) or ulcerative colitis (UC) published before February 2021. RESULTS Twenty-nine studies were identified comprising 288 patients started on DTT for partially or non-responsive IBD. We identified 14 studies with 113 patients receiving anti-tumor necrosis factor (TNF) and anti-integrin therapies (i.e., vedolizumab and natalizumab), 12 studies with 55 patients receiving vedolizumab and ustekinumab, nine studies with 68 patients receiving vedolizumab and tofacitinib, five studies with 24 patients receiving anti-TNF therapy and tofacitinib, six studies with 18 patients receiving anti-TNF therapy and ustekinumab, and three studies with 13 patients receiving ustekinumab and tofacitinib. CONCLUSION DTT is a promising approach to improve IBD treatment for patients with incomplete responses to targeted monotherapy. Larger prospective clinical studies are needed to confirm these findings as is additional predictive modeling to identify the patient subgroups most likely to require and benefit from this approach.
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Affiliation(s)
- Elliot M Berinstein
- Department of Medicine, Trinity Health Ann Arbor Hospital, Ypsilanti, MI, USA
| | - Jessica L Sheehan
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Michigan Medicine, 1500 E. Medical Center Drive, Ann Arbor, MI, 48109, USA
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, USA
| | - Janson Jacob
- Department of Internal Medicine, Michigan Medicine, Ann Arbor, MI, USA
| | - Calen A Steiner
- Division of Gastroenterology and Hepatology, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Ryan W Stidham
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Michigan Medicine, 1500 E. Medical Center Drive, Ann Arbor, MI, 48109, USA
- Department of Computational Medicine and Bioinformatics, University of Michigan, Ann Arbor, MI, USA
| | - Carol Shannon
- Taubman Health Sciences Library, University of Michigan, Ann Arbor, MI, USA
| | - Shrinivas Bishu
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Michigan Medicine, 1500 E. Medical Center Drive, Ann Arbor, MI, 48109, USA
| | - Jake Levine
- Department of Internal Medicine, Michigan Medicine, Ann Arbor, MI, USA
| | - Shirley A Cohen-Mekelburg
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Michigan Medicine, 1500 E. Medical Center Drive, Ann Arbor, MI, 48109, USA
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, USA
- VA Center for Clinical Management Research, VA Ann Arbor Health Care System, Ann Arbor, MI, USA
| | - Akbar K Waljee
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Michigan Medicine, 1500 E. Medical Center Drive, Ann Arbor, MI, 48109, USA
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, USA
- VA Center for Clinical Management Research, VA Ann Arbor Health Care System, Ann Arbor, MI, USA
- Department of Learning Health Sciences, University of Michigan, Ann Arbor, MI, USA
| | - Peter D R Higgins
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Michigan Medicine, 1500 E. Medical Center Drive, Ann Arbor, MI, 48109, USA
| | - Jeffrey A Berinstein
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Michigan Medicine, 1500 E. Medical Center Drive, Ann Arbor, MI, 48109, USA.
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, USA.
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Irfan FB, Telford B, Hollon N, Dehghani A, Schukow C, Syed AY, Rego RT, Waljee AK, Cunningham W, Ahmed FS. Coronavirus pandemic in the South Asia region: Health policy and economy trade-off. J Glob Health 2023; 13:06014. [PMID: 37141526 PMCID: PMC10159594 DOI: 10.7189/jogh.13.06014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/06/2023] Open
Abstract
Background The South Asian Association for Regional Cooperation (SAARC) covers Afghanistan, Bangladesh, Bhutan, India, Maldives, Nepal, Pakistan, and Sri Lanka. We conducted a comparative analysis of the trade-off between the health policies for the prevention of COVID-19 spread and the impact of these policies on the economies and livelihoods of the South Asia populations. Methods We analyzed COVID-19 data on epidemiology, public health and health policy, health system capacity, and macroeconomic indicators from January 2020 to March 2021 to determine temporal trends by conducting joinpoint regression analysis using average weekly percent change (AWPC). Results Bangladesh had the highest statistically significant AWPC for new COVID-19 cases (17.0; 95% CI = 7.7-27.1, P < 0.001), followed by the Maldives (12.9; 95% CI = 5.3-21.0, P < 0.001) and India (10.0; 95% CI = 8.4-11.5, P < 0.001). The AWPC for COVID-19 deaths was significant for India (6.5; 95% CI = 4.3-8.9, P < 0.001) and Bangladesh (6.1; 95% CI = 3.7-8.5, P < 0.001). Nepal (55.79%), and India (34.91%) had the second- and third-highest increase in unemployment, while Afghanistan (6.83%) and Pakistan (16.83%) had the lowest. The rate of change of real GDP had the highest decrease for Maldives (557.51%), and India (297.03%); Pakistan (46.46%) and Bangladesh (70.80%), however, had the lowest decrease. The government response stringency index for Pakistan had a see-saw pattern with a sharp decline followed by an increase in the government health policy restrictions that approximated the test-positivity trend. Conclusions Unlike developed economies, the South Asian developing countries experienced a trade-off between health policy and their economies during the COVID-19 pandemic. South Asian countries (Nepal and India), with extended periods of lockdowns and a mismatch between temporal trends of government response stringency index and the test-positivity or disease incidence, had higher adverse economic effects, unemployment, and burden of COVID-19. Pakistan demonstrated targeted lockdowns with a rapid see-saw pattern of government health policy response that approximated the test-positivity trend and resulted in lesser adverse economic effects, unemployment, and burden of COVID-19.
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Affiliation(s)
- Furqan B Irfan
- Institute of Global Health, Michigan State University, East Lansing, Michigan, USA
- Department of Neurology and Ophthalmology, College of Osteopathic Medicine, Michigan State University, East Lansing, Michigan, USA
| | - Ben Telford
- College of Osteopathic Medicine, Michigan State University, East Lansing, Michigan, USA
| | - Nick Hollon
- College of Osteopathic Medicine, Michigan State University, East Lansing, Michigan, USA
| | - Ali Dehghani
- College of Osteopathic Medicine, Michigan State University, East Lansing, Michigan, USA
| | - Casey Schukow
- College of Osteopathic Medicine, Michigan State University, East Lansing, Michigan, USA
| | | | - Ryan T Rego
- Center for Global Health Equity, University of Michigan, Ann Arbor, Michigan, USA
| | - Akbar K Waljee
- Center for Global Health Equity, University of Michigan, Ann Arbor, Michigan, USA
- Department of Learning Health Sciences, University of Michigan, Ann Arbor, Michigan, USA
- Michigan Integrated Center for Health Analytics and Medical Prediction (MiCHAMP), University of Michigan, Ann Arbor, Michigan, USA
| | - William Cunningham
- Institute of Global Health, Michigan State University, East Lansing, Michigan, USA
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20
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Greene-Higgs L, Jordan A, Sheehan J, Berinstein J, Admon AJ, Waljee AK, Riehl M, Piette J, Resnicow K, Higgins PD, Cohen-Mekelburg S. Social Network Diversity and the Daily Burden of Inflammatory Bowel Disease. Clin Transl Gastroenterol 2023; 14:e00572. [PMID: 36854057 PMCID: PMC10208714 DOI: 10.14309/ctg.0000000000000572] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2023] [Accepted: 02/13/2023] [Indexed: 03/02/2023] Open
Abstract
INTRODUCTION To examine the association between social network, daily inflammatory bowel disease (IBD) burden, and related cognitive factors such as loneliness and psychological well-being. METHODS Using survey data, we compared the relationship between social network diversity and daily IBD burden with multivariable linear regression. RESULTS Patients with IBD with higher social network diversity reported a lower daily IBD burden. This association was more common among those who reported a higher degree of loneliness than those with a low degree of loneliness. DISCUSSION We should consider diverse social connections as an indicator of risk for higher IBD burden, especially among lonely patients.
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Affiliation(s)
- LaVana Greene-Higgs
- Department of Internal Medicine, University of Michigan Medicine, Ann Arbor, Michigan, USA
| | - Ariel Jordan
- Department of Internal Medicine, University of Michigan Medicine, Ann Arbor, Michigan, USA
| | - Jessica Sheehan
- Division of Gastroenterology & Hepatology, University of Michigan Medicine, Ann Arbor, Michigan, USA
| | - Jeffrey Berinstein
- Division of Gastroenterology & Hepatology, University of Michigan Medicine, Ann Arbor, Michigan, USA
| | - Andrew J. Admon
- Division of Pulmonary and Critical Care Medicine, University of Michigan Medicine, Ann Arbor, Michigan, USA
- VA Center for Clinical Management Research, VA Ann Arbor Health System, Ann Arbor, Michigan, USA
| | - Akbar K. Waljee
- Division of Gastroenterology & Hepatology, University of Michigan Medicine, Ann Arbor, Michigan, USA
- VA Center for Clinical Management Research, VA Ann Arbor Health System, Ann Arbor, Michigan, USA
| | - Megan Riehl
- Division of Gastroenterology & Hepatology, University of Michigan Medicine, Ann Arbor, Michigan, USA
| | - John Piette
- VA Center for Clinical Management Research, VA Ann Arbor Health System, Ann Arbor, Michigan, USA
- Department of Health Behavior and Health Education, University of Michigan School of Public Health, Ann Arbor, Michigan, USA
| | - Kenneth Resnicow
- Department of Health Behavior and Health Education, University of Michigan School of Public Health, Ann Arbor, Michigan, USA
| | - Peter D. Higgins
- Division of Gastroenterology & Hepatology, University of Michigan Medicine, Ann Arbor, Michigan, USA
| | - Shirley Cohen-Mekelburg
- Division of Gastroenterology & Hepatology, University of Michigan Medicine, Ann Arbor, Michigan, USA
- VA Center for Clinical Management Research, VA Ann Arbor Health System, Ann Arbor, Michigan, USA
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21
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Rubenstein JH, Burns JA, Arasim ME, Firsht EM, Harbrecht M, Widerquist M, Evans RR, Inadomi JM, Chang JW, Hazelton WD, Hur C, Kurlander JE, Lim F, Luebeck G, Macdonald PW, Reddy CA, Saini SD, Tan SX, Waljee AK, Lansdorp-Vogelaar I. Yield of Repeat Endoscopy for Barrett's Esophagus After Normal Index Endoscopy. Am J Gastroenterol 2023:00000434-990000000-00667. [PMID: 36716445 DOI: 10.14309/ajg.0000000000002204] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2022] [Accepted: 01/19/2023] [Indexed: 02/01/2023]
Abstract
INTRODUCTION Guidelines suggest 1-time screening with esophagogastroduodenoscopy (EGD) for Barrett's esophagus (BE) in individuals at an increased risk of esophageal adenocarcinoma (EAC). We aimed to estimate the yield of repeat EGD performed at prolonged intervals after a normal index EGD. METHODS We conducted a national retrospective analysis within the U S Veterans Health Administration, identifying patients with a normal index EGD between 2003 and 2009 who subsequently had a repeat EGD. We tabulated the proportion with a new diagnosis of BE, EAC, or esophagogastric junction adenocarcinoma (EGJAC) and conducted manual chart review of a sample. We fitted logistic regression models for the odds of a new diagnosis of BE/EAC/EGJAC. RESULTS We identified 71,216 individuals who had a repeat EGD between 1 and 16 years after an index EGD without billing or cancer registry codes for BE/EAC/EGJAC. Of them, 4,088 had a new billing or cancer registry code for BE/EAC/EGJAC after the repeat EGD. On manual review of a stratified sample, most did not truly have new BE/EAC/EGJAC. A longer duration between EGD was associated with greater odds of a new diagnosis (adjusted odds ratio [aOR] for each 5 years 1.31; 95% confidence interval [CI] 1.19-1.44), particularly among those who were younger during the index EGD (ages 19-29 years: aOR 3.92; 95% CI 1.24-12.4; ages 60-69 years: aOR 1.19; 95% CI 1.01-1.40). DISCUSSION The yield of repeat EGD for BE/EAC/EGJAC seems to increase with time after a normal index EGD, particularly for younger individuals. Prospective studies are warranted to confirm these findings.
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Affiliation(s)
- Joel H Rubenstein
- Veterans Affairs Center for Clinical Management Research, LTC Charles S. Kettles Veterans Affairs Medical Center, Ann Arbor, Michigan, USA
- Division of Gastroenterology, Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, Michigan, USA
- Rogel Cancer Center, University of Michigan Medical School, Ann Arbor, Michigan, USA
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, Michigan, USA
| | - Jennifer A Burns
- Veterans Affairs Center for Clinical Management Research, LTC Charles S. Kettles Veterans Affairs Medical Center, Ann Arbor, Michigan, USA
| | - Maria E Arasim
- Veterans Affairs Center for Clinical Management Research, LTC Charles S. Kettles Veterans Affairs Medical Center, Ann Arbor, Michigan, USA
| | - Elizabeth M Firsht
- Veterans Affairs Center for Clinical Management Research, LTC Charles S. Kettles Veterans Affairs Medical Center, Ann Arbor, Michigan, USA
| | - Matthew Harbrecht
- Division of Gastroenterology, Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, Michigan, USA
| | - Marilla Widerquist
- Veterans Affairs Center for Clinical Management Research, LTC Charles S. Kettles Veterans Affairs Medical Center, Ann Arbor, Michigan, USA
| | - Richard R Evans
- Veterans Affairs Center for Clinical Management Research, LTC Charles S. Kettles Veterans Affairs Medical Center, Ann Arbor, Michigan, USA
| | - John M Inadomi
- Department of Internal Medicine, University of Utah, Salt Lake City, Utah, USA
| | - Joy W Chang
- Division of Gastroenterology, Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, Michigan, USA
| | - William D Hazelton
- Computational Biology Program, Fred Hutchinson Cancer Center, Seattle, Washington, USA
| | - Chin Hur
- Division of General Medicine, Department of Medicine, Columbia University Irving Medical Center, New York, New York, USA
| | - Jacob E Kurlander
- Veterans Affairs Center for Clinical Management Research, LTC Charles S. Kettles Veterans Affairs Medical Center, Ann Arbor, Michigan, USA
- Division of Gastroenterology, Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, Michigan, USA
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, Michigan, USA
| | - Francesca Lim
- Division of General Medicine, Department of Medicine, Columbia University Irving Medical Center, New York, New York, USA
| | - Georg Luebeck
- Computational Biology Program, Fred Hutchinson Cancer Center, Seattle, Washington, USA
| | - Peter W Macdonald
- Department of Statistics, University of Michigan College of Literature, Science, and Arts, Ann Arbor, Michigan, USA
| | - Chanakyaram A Reddy
- Center for Esophageal Diseases, Baylor, Scott & White Health, Dallas, Texas, USA
| | - Sameer D Saini
- Veterans Affairs Center for Clinical Management Research, LTC Charles S. Kettles Veterans Affairs Medical Center, Ann Arbor, Michigan, USA
- Division of Gastroenterology, Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, Michigan, USA
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, Michigan, USA
| | - Sarah Xinhui Tan
- Division of General Medicine, Department of Medicine, Columbia University Irving Medical Center, New York, New York, USA
| | - Akbar K Waljee
- Veterans Affairs Center for Clinical Management Research, LTC Charles S. Kettles Veterans Affairs Medical Center, Ann Arbor, Michigan, USA
- Division of Gastroenterology, Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, Michigan, USA
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, Michigan, USA
| | - Iris Lansdorp-Vogelaar
- Department of Public Health, Erasmus MC University Medical Center Rotterdam, the Netherlands
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22
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Cohen-Mekelburg S, Greene L, Berinstein J, Waljee AK, Hofer TP, Saini SD, Zulman DM. Distinct health care use patterns of patients with chronic gastrointestinal diseases. Am J Manag Care 2023; 29:e71-e78. [PMID: 36947019 DOI: 10.37765/ajmc.2023.89332] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/17/2023]
Abstract
OBJECTIVES Patients with complex chronic conditions have varying multidisciplinary care needs and utilization patterns, which limit the effectiveness of initiatives designed to improve continuity of care (COC) and reduce utilization. Our objective was to categorize patients with complex chronic conditions into distinct groups by pattern of outpatient care use and COC to tailor interventions. STUDY DESIGN Observational cohort study from 2014 to 2015. METHODS We identified patients whose 1-year hospitalization risk was in at least the 90th percentile in 2014 who had a chronic gastrointestinal disease (cirrhosis, inflammatory bowel disease, chronic pancreatitis) as case examples of complex chronic disease. We described frequency of office visits, number of outpatient providers, and 2 COC measures (usual provider of care, Bice-Boxerman COC indices) over 12 months. We used latent profile analysis, a statistical method for identifying distinct subgroups, to categorize patients based on overall, primary care, gastroenterology, and mental health continuity patterns. RESULTS The 26,751 veterans in the cohort had a mean (SD) of 13.3 (8.6) office visits and 7.2 (3.8) providers in 2014. Patients were classified into 5 subgroups: (1) high gastroenterology-specific COC with mental health use; (2) high gastroenterology-specific COC without mental health use; (3) high overall utilization with mental health use; (4) low overall COC with mental health use; and (5) low overall COC without mental health use. These groups varied in their sociodemographic characteristics and risk for hospitalization, emergency department use, and mortality. CONCLUSIONS Patients at high risk for health care utilization with specialty care needs can be grouped by varying propensity for health care continuity patterns.
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23
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Read AJ, Zhou W, Saini SD, Zhu J, Waljee AK. Prediction of Gastrointestinal Tract Cancers Using Longitudinal Electronic Health Record Data. Cancers (Basel) 2023; 15:cancers15051399. [PMID: 36900192 PMCID: PMC10000707 DOI: 10.3390/cancers15051399] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2022] [Revised: 02/17/2023] [Accepted: 02/20/2023] [Indexed: 02/25/2023] Open
Abstract
BACKGROUND Luminal gastrointestinal (GI) tract cancers, including esophageal, gastric, small bowel, colorectal, and anal cancers, are often diagnosed at late stages. These tumors can cause gradual GI bleeding, which may be unrecognized but detectable by subtle laboratory changes. Our aim was to develop models to predict luminal GI tract cancers using laboratory studies and patient characteristics using logistic regression and random forest machine learning methods. METHODS The study was a single-center, retrospective cohort at an academic medical center, with enrollment between 2004-2013 and with follow-up until 2018, who had at least two complete blood counts (CBCs). The primary outcome was the diagnosis of GI tract cancer. Prediction models were developed using multivariable single timepoint logistic regression, longitudinal logistic regression, and random forest machine learning. RESULTS The cohort included 148,158 individuals, with 1025 GI tract cancers. For 3-year prediction of GI tract cancers, the longitudinal random forest model performed the best, with an area under the receiver operator curve (AuROC) of 0.750 (95% CI 0.729-0.771) and Brier score of 0.116, compared to the longitudinal logistic regression model, with an AuROC of 0.735 (95% CI 0.713-0.757) and Brier score of 0.205. CONCLUSIONS Prediction models incorporating longitudinal features of the CBC outperformed the single timepoint logistic regression models at 3-years, with a trend toward improved accuracy of prediction using a random forest machine learning model compared to a longitudinal logistic regression model.
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Affiliation(s)
- Andrew J. Read
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, University of Michigan, Ann Arbor, MI 48109, USA
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI 48109, USA
- Michigan Integrated Center for Health Analytics and Medical Prediction, University of Michigan, Ann Arbor, MI 48109, USA
- Correspondence: (A.J.R.); (W.Z.); Tel.: +1-(734)-936-4785 (A.J.R.); Fax: +1-(734)-936-5458 (A.J.R.)
| | - Wenjing Zhou
- Department of Statistics, University of Michigan, Ann Arbor, MI 48109, USA
- Correspondence: (A.J.R.); (W.Z.); Tel.: +1-(734)-936-4785 (A.J.R.); Fax: +1-(734)-936-5458 (A.J.R.)
| | - Sameer D. Saini
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, University of Michigan, Ann Arbor, MI 48109, USA
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI 48109, USA
- Michigan Integrated Center for Health Analytics and Medical Prediction, University of Michigan, Ann Arbor, MI 48109, USA
- VA HSR&D Center for Clinical Management Research, Ann Arbor, MI 48105, USA
| | - Ji Zhu
- Michigan Integrated Center for Health Analytics and Medical Prediction, University of Michigan, Ann Arbor, MI 48109, USA
- Department of Statistics, University of Michigan, Ann Arbor, MI 48109, USA
| | - Akbar K. Waljee
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, University of Michigan, Ann Arbor, MI 48109, USA
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI 48109, USA
- Michigan Integrated Center for Health Analytics and Medical Prediction, University of Michigan, Ann Arbor, MI 48109, USA
- VA HSR&D Center for Clinical Management Research, Ann Arbor, MI 48105, USA
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24
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De Lott LB, Lin CC, Burke JF, Wallace B, Saukkonen D, Waljee AK, Kerber KA. Predictors of Glucocorticoid Use for Acute Optic Neuritis in the United States, 2005-2019. Ophthalmic Epidemiol 2023; 30:88-94. [PMID: 35168450 PMCID: PMC9378755 DOI: 10.1080/09286586.2022.2034167] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2021] [Revised: 01/10/2022] [Accepted: 01/21/2022] [Indexed: 10/19/2022]
Abstract
PURPOSE Acute optic neuritis (ON) is variably treated with glucocorticoids. We aimed to describe factors associated with glucocorticoid use. METHODS In this retrospective, longitudinal cohort study of insured patients in the United States (2005-2019), adults 18-50 years old with one inpatient or ≥2 outpatient diagnoses of ON within 90 days were included. Glucocorticoid use was classified as none, any dose, and high-dose (>100 mg prednisone equivalent ≥1 days). The primary outcome was glucocorticoid receipt within 90 days of the first ON diagnosis. Multivariable logistic regression models assessed the relationship between glucocorticoid use and sociodemographics, comorbidities, clinician specialty, visit number, and year. RESULTS Of 3026 people with ON, 65.8% were women (n = 1991), median age (interquartile range) was 38 years (31,44), and 68.6% were white (n = 2075). Glucocorticoids were received by 46% (n = 1385); 54.6% (n = 760/1385) of whom received high-dose. The odds of receiving glucocorticoids were higher among patients with multiple sclerosis (OR 1.61 [95%CI 1.28-2.04]; P < .001), MRI (OR 1.75 [95%CI 1.09-2.80]; P = .02), 3 (OR 1.80 [95%CI 1.46-2.22]; P < .001) or more (OR 4.08 [95%CI 3.37-4.95]; P < .001) outpatient ON visits, and in certain regions. Compared to ophthalmologists, patients diagnosed by neurologists (OR 1.36 [95%CI: 1.10-1.69], p = .005), emergency medicine (OR 3.97 [95%CI: 2.66-5.94]; P < .001) or inpatient clinicians (OR 2.94 [95%CI: 2.22-3.90]; P < .001) had higher odds of receiving glucocorticoids. Use increased 1.1% annually (P < .001). CONCLUSIONS Demyelinating disease, care intensity, setting, region, and clinician type were associated with glucocorticoid use for ON. To optimize care, future studies should explore reasons for ON care variation, and patient/clinician preferences.
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Affiliation(s)
- Lindsey B. De Lott
- Department of Neurology, Michigan Medicine, Ann Arbor, Michigan
- Institute for Healthcare Policy and Innovation, Michigan Medicine, Ann Arbor Michigan
| | - Chun Chieh Lin
- Department of Neurology, Michigan Medicine, Ann Arbor, Michigan
- Institute for Healthcare Policy and Innovation, Michigan Medicine, Ann Arbor Michigan
| | - James F. Burke
- Department of Neurology, Michigan Medicine, Ann Arbor, Michigan
- Institute for Healthcare Policy and Innovation, Michigan Medicine, Ann Arbor Michigan
| | - Beth Wallace
- Institute for Healthcare Policy and Innovation, Michigan Medicine, Ann Arbor Michigan
- Department of Internal Medicine, Michigan Medicine, Ann Arbor, Michigan
- VA Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, Michigan, USA
| | | | - Akbar K. Waljee
- Institute for Healthcare Policy and Innovation, Michigan Medicine, Ann Arbor Michigan
- Department of Internal Medicine, Michigan Medicine, Ann Arbor, Michigan
- VA Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, Michigan, USA
| | - Kevin A. Kerber
- Department of Neurology, Michigan Medicine, Ann Arbor, Michigan
- Institute for Healthcare Policy and Innovation, Michigan Medicine, Ann Arbor Michigan
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Rego RT, Kenney B, Ngugi AK, Espira L, Orwa J, Siwo GH, Sefa C, Shah J, Weinheimer-Haus E, Sophie Delius AJ, Pape UJ, Irfan FB, Abubakar A, Shah R, Wagner A, Kolars J, Boulton ML, Hofer T, Waljee AK. COVID-19 vaccination refusal trends in Kenya over 2021. Vaccine 2023; 41:1161-1168. [PMID: 36624011 PMCID: PMC9808414 DOI: 10.1016/j.vaccine.2022.12.066] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2022] [Revised: 12/23/2022] [Accepted: 12/30/2022] [Indexed: 01/04/2023]
Abstract
BACKGROUND Vaccination refusal exacerbates global COVID-19 vaccination inequities. No studies in East Africa have examined temporal trends in vaccination refusal, precluding addressing refusal. We assessed vaccine refusal over time in Kenya, and characterized factors associated with changes in vaccination refusal. METHODS We analyzed data from the Kenya Rapid Response Phone Survey (RRPS), a household cohort survey representative of the Kenyan population including refugees. Vaccination refusal (defined as the respondent stating they would not receive the vaccine if offered to them at no cost) was measured in February and October 2021. Proportions of vaccination refusal were plotted over time. We analyzed factors in vaccination refusal using a weighted multivariable logistic regression including interactions for time. FINDINGS Among 11,569 households, vaccination refusal in Kenya decreased from 24 % in February 2021 to 9 % in October 2021. Vaccination refusal was associated with having education beyond the primary level (-4.1[-0.7,-8.9] percentage point difference (ppd)); living with somebody who had symptoms of COVID-19 in the past 14 days (-13.72[-8.9,-18.6]ppd); having symptoms of COVID-19 in the past 14 days (11.0[5.1,16.9]ppd); and distrusting the government in responding to COVID-19 (14.7[7.1,22.4]ppd). There were significant interactions with time and: refugee status and geography, living with somebody with symptoms of COVID-19, having symptoms of COVID-19, and believing in misinformation. INTERPRETATION The temporal reduction in vaccination refusal in Kenya likely represents substantial strides by the Kenyan vaccination program and possible learnt lessons which require examination. Going forward, there are still several groups which need specific targeting to decrease vaccination refusal and improve vaccination equity, including those with lower levels of education, those with recent COVID-19 symptoms, those who do not practice personal COVID-19 mitigation measures, refugees in urban settings, and those who do not trust the government. Policy and program should focus on decreasing vaccination refusal in these populations, and research focus on understanding barriers and motivators for vaccination.
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Affiliation(s)
- Ryan T. Rego
- Center for Global Health Equity, University of Michigan, Ann Arbor, MI, USA,Corresponding author
| | - Brooke Kenney
- Center for Global Health Equity, University of Michigan, Ann Arbor, MI, USA,Department of Internal Medicine, Michigan Medicine, Ann Arbor, MI, USA
| | - Anthony K. Ngugi
- Department of Population Health, Aga Khan University, Nairobi, Kenya
| | - Leon Espira
- Center for Global Health Equity, University of Michigan, Ann Arbor, MI, USA
| | - James Orwa
- Department of Population Health, Aga Khan University, Nairobi, Kenya
| | - Geoffrey H. Siwo
- Center for Global Health Equity, University of Michigan, Ann Arbor, MI, USA,Department of Internal Medicine, Michigan Medicine, Ann Arbor, MI, USA
| | - Christabel Sefa
- Center for Global Health Equity, University of Michigan, Ann Arbor, MI, USA
| | - Jasmit Shah
- Department of Internal Medicine, Aga Khan University, Nairobi, Kenya,Brain and Mind Institute, Aga Khan University, Nairobi, Kenya
| | - Eileen Weinheimer-Haus
- Center for Global Health Equity, University of Michigan, Ann Arbor, MI, USA,Department of Internal Medicine, Michigan Medicine, Ann Arbor, MI, USA
| | | | - Utz Johann Pape
- World Bank Group, Washington, DC, USA,University of Goettingen, Goettingen, Germany
| | - Furqan B. Irfan
- Institute of Global Health, Michigan State University, Lansing, MI, USA
| | - Amina Abubakar
- Institute for Human Development, Aga Khan University, Nairobi, Kenya
| | - Reena Shah
- Department of Internal Medicine, Aga Khan University, Nairobi, Kenya
| | - Abram Wagner
- School of Public Health, University of Michigan, Ann Arbor, MI, USA
| | - Joseph Kolars
- Center for Global Health Equity, University of Michigan, Ann Arbor, MI, USA,Department of Internal Medicine, Michigan Medicine, Ann Arbor, MI, USA
| | | | - Timothy Hofer
- Center for Global Health Equity, University of Michigan, Ann Arbor, MI, USA,Department of Internal Medicine, Michigan Medicine, Ann Arbor, MI, USA
| | - Akbar K. Waljee
- Center for Global Health Equity, University of Michigan, Ann Arbor, MI, USA,Department of Internal Medicine, Michigan Medicine, Ann Arbor, MI, USA,Michigan Integrated Center for Health Analytics and Medical Prediction (MiCHAMP), Ann Arbor, MI, USA
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26
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Cohen-Mekelburg S, Van T, Yu X, Costa DK, Manojlovich M, Saini S, Gilmartin H, Admon AJ, Resnicow K, Higgins PDR, Siwo G, Zhu J, Waljee AK. Understanding clinician connections to inform efforts to promote high-quality inflammatory bowel disease care. PLoS One 2022; 17:e0279441. [PMID: 36574370 PMCID: PMC9794045 DOI: 10.1371/journal.pone.0279441] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2022] [Accepted: 12/07/2022] [Indexed: 12/28/2022] Open
Abstract
BACKGROUND Highly connected individuals disseminate information effectively within their social network. To apply this concept to inflammatory bowel disease (IBD) care and lay the foundation for network interventions to disseminate high-quality treatment, we assessed the need for improving the IBD practices of highly connected clinicians. We aimed to examine whether highly connected clinicians who treat IBD patients were more likely to provide high-quality treatment than less connected clinicians. METHODS We used network analysis to examine connections among clinicians who shared patients with IBD in the Veterans Health Administration between 2015-2018. We created a network comprised of clinicians connected by shared patients. We quantified clinician connections using degree centrality (number of clinicians with whom a clinician shares patients), closeness centrality (reach via shared contacts to other clinicians), and betweenness centrality (degree to which a clinician connects clinicians not otherwise connected). Using weighted linear regression, we examined associations between each measure of connection and two IBD quality indicators: low prolonged steroids use, and high steroid-sparing therapy use. RESULTS We identified 62,971 patients with IBD and linked them to 1,655 gastroenterologists and 7,852 primary care providers. Clinicians with more connections (degree) were more likely to exhibit high-quality treatment (less prolonged steroids beta -0.0268, 95%CI -0.0427, -0.0110, more steroid-sparing therapy beta 0.0967, 95%CI 0.0128, 0.1805). Clinicians who connect otherwise unconnected clinicians (betweenness) displayed more prolonged steroids use (beta 0.0003, 95%CI 0.0001, 0.0006). The presence of variation is more relevant than its magnitude. CONCLUSIONS Clinicians with a high number of connections provided more high-quality IBD treatments than less connected clinicians, and may be well-positioned for interventions to disseminate high-quality IBD care. However, clinicians who connect clinicians who are otherwise unconnected are more likely to display low-quality IBD treatment. Efforts to improve their quality are needed prior to leveraging their position to disseminate high-quality care.
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Affiliation(s)
- Shirley Cohen-Mekelburg
- VA Center for Clinical Management Research, LTC Charles Kettles VA Medical Center, Ann Arbor, Michigan, United States of America
- Division of Gastroenterology & Hepatology, University of Michigan Medicine, Ann Arbor, Michigan, United States of America
| | - Tony Van
- VA Center for Clinical Management Research, LTC Charles Kettles VA Medical Center, Ann Arbor, Michigan, United States of America
| | - Xianshi Yu
- Department of Statistics, University of Michigan Medicine, Ann Arbor, Michigan, United States of America
| | - Deena Kelly Costa
- School of Nursing, Yale University, New Haven, Connecticut, United States of America
- Section on Pulmonary, Critical Care & Sleep Medicine, Department of Internal Medicine, Yale University, New Haven, Connecticut, United States of America
| | - Milisa Manojlovich
- School of Nursing, Yale University, New Haven, Connecticut, United States of America
- Section on Pulmonary, Critical Care & Sleep Medicine, Department of Internal Medicine, Yale University, New Haven, Connecticut, United States of America
| | - Sameer Saini
- VA Center for Clinical Management Research, LTC Charles Kettles VA Medical Center, Ann Arbor, Michigan, United States of America
- Division of Gastroenterology & Hepatology, University of Michigan Medicine, Ann Arbor, Michigan, United States of America
| | - Heather Gilmartin
- Denver/Seattle Center of Innovation, VA Eastern Colorado Healthcare System, Aurora, Colorado, United States of America
| | - Andrew J. Admon
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Michigan Medicine, Ann Arbor, Michigan, United States of America
- Pulmonary Service, LTC Charles Kettles VA Medical Center, Ann Arbor, Michigan, United States of America
| | - Ken Resnicow
- Department of Health Education and Health Behavior, University of Michigan School of Public Health, Ann Arbor, Michigan, United States of America
| | - Peter D. R. Higgins
- Division of Gastroenterology & Hepatology, University of Michigan Medicine, Ann Arbor, Michigan, United States of America
| | - Geoffrey Siwo
- Division of Gastroenterology & Hepatology, University of Michigan Medicine, Ann Arbor, Michigan, United States of America
| | - Ji Zhu
- Department of Statistics, University of Michigan Medicine, Ann Arbor, Michigan, United States of America
| | - Akbar K. Waljee
- VA Center for Clinical Management Research, LTC Charles Kettles VA Medical Center, Ann Arbor, Michigan, United States of America
- Division of Gastroenterology & Hepatology, University of Michigan Medicine, Ann Arbor, Michigan, United States of America
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27
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Jacob J, Aintabi D, DeJonckheere M, Cohen-Mekelburg SA, Allen JI, Irani DN, Fendrick AM, Waljee AK, Higgins PDR, Berinstein JA. Inflammatory bowel disease patient concerns and experiences on transition to home-based infusions during the COVID-19 pandemic. Res Social Adm Pharm 2022; 18:4138-4143. [PMID: 35871146 PMCID: PMC9238022 DOI: 10.1016/j.sapharm.2022.06.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2021] [Revised: 05/12/2022] [Accepted: 06/24/2022] [Indexed: 11/28/2022]
Abstract
BACKGROUND In response to the COVID-19 pandemic, the CDC issued guidance advising patients and providers to adopt social distancing practices such as home-based infusions (H-BI). METHODS We performed a mixed methods evaluation to summarize perceptions, concerns, and experiences with H-BI among all inflammatory bowel disease patients 18-90 years of age who transitioned to home-based infliximab or vedolizumab infusions between March to July 2020 at a tertiary care center. Semi-structured interviews were conducted and analyzed using an iterative, inductive thematic approach. Baseline characteristics and outcome on safety, COVID-19 transmission, delays in infusions, and H-BI persistence were collected. RESULTS Of the 57 participants who transitioned to H-BI, 20 (33%) responded. Four major categories and six major themes related to expectations, experience, perceived safety, and logistical factors were identified. Initial perceptions were mixed, however these resolved. One patient developed COVID-19, one patient experienced an adverse event, 12 (21%) patients experienced an infusion delay, and 6 (11%) patients transitioned from H-BI. DISCUSSION Despite mixed initial perceptions, respondents had a positive experience with most respondents planning to continue H-BI after the pandemic resolves. Several real-world actionable barriers were identified related to scheduling, communication between stakeholders, and nursing quality. No major safety concerns were identified.
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Affiliation(s)
- Janson Jacob
- Department of Internal Medicine, Michigan Medicine, Ann Arbor, MI, USA
| | - Daniel Aintabi
- Department of Medicine, St. Joseph Mercy Ann Arbor Hospital, Ypsilanti, MI, USA
| | - Melissa DeJonckheere
- Department of Family Medicine, University of Michigan, Ann Arbor, MI, USA; Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, USA
| | - Shirley A Cohen-Mekelburg
- Department of Internal Medicine, Michigan Medicine, Ann Arbor, MI, USA; Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, USA; VA Center for Clinical Management Research, VA Ann Arbor Health Care System, Ann Arbor, MI, USA; Division of Gastroenterology and Hepatology, Michigan Medicine, Ann Arbor, MI, USA
| | - John I Allen
- Department of Internal Medicine, Michigan Medicine, Ann Arbor, MI, USA; Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, USA; Division of Gastroenterology and Hepatology, Michigan Medicine, Ann Arbor, MI, USA
| | - David N Irani
- Department of Neurology, University of Michigan Medical School, Ann Arbor, MI, USA
| | - A Mark Fendrick
- Department of Internal Medicine, Michigan Medicine, Ann Arbor, MI, USA; Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, USA; Center for Value-Based Insurance Design, University of Michigan, Ann Arbor, MI, USA
| | - Akbar K Waljee
- Department of Internal Medicine, Michigan Medicine, Ann Arbor, MI, USA; Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, USA; VA Center for Clinical Management Research, VA Ann Arbor Health Care System, Ann Arbor, MI, USA; Division of Gastroenterology and Hepatology, Michigan Medicine, Ann Arbor, MI, USA
| | - Peter D R Higgins
- Department of Internal Medicine, Michigan Medicine, Ann Arbor, MI, USA; Division of Gastroenterology and Hepatology, Michigan Medicine, Ann Arbor, MI, USA
| | - Jeffrey A Berinstein
- Department of Internal Medicine, Michigan Medicine, Ann Arbor, MI, USA; Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, USA; Division of Gastroenterology and Hepatology, Michigan Medicine, Ann Arbor, MI, USA.
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28
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Kim HS, Hernaez R, Sansgiry S, Waljee AK, Scott FI, Lewis JD, El-Serag HB, Hou JK. Comparative Effectiveness of Surveillance Colonoscopy Intervals on Colorectal Cancer Outcomes in a National Cohort of Patients with Inflammatory Bowel Disease. Clin Gastroenterol Hepatol 2022; 20:2848-2857.e2. [PMID: 35240331 PMCID: PMC9489337 DOI: 10.1016/j.cgh.2022.02.048] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2021] [Revised: 01/20/2022] [Accepted: 02/17/2022] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Surveillance colonoscopy is recommended to reduce colorectal cancer (CRC)-related morbidity and mortality in patients with inflammatory bowel disease (IBD). The comparative effectiveness of varying colonoscopy intervals on CRC outcomes among patients with IBD is unknown. METHODS We performed a retrospective cohort study of patients with confirmed CRC within a cohort of 77,824 patients with IBD during 2000 to 2015 in the National Veterans Health Administration. We examined the association between colonoscopy surveillance intervals on CRC stage, treatment, or all-cause and cancer-specific mortality. The interval of colonoscopy prior to CRC diagnosis was categorized as those performed within <1 year, 1 to 3 years, 3 to 5 years, or none within 5 years. RESULTS Among 566 patients with CRC-IBD, most (69.4%) did not have colonoscopy within 5 years prior to CRC diagnosis, whereas 9.7% had colonoscopy within 1 year prior to diagnosis, 17.7% within 1 to 3 years, and 3.1% between 3 and 5 years. Compared with no surveillance, colonoscopy within 1 year (adjusted odds ratio, 0.40; 95% confidence interval [CI], 0.20-0.82), and 1 to 3 years (adjusted odds ratio, 0.56; 95% CI, 0.32-0.98) were less likely to be diagnosed at late stage. Regardless of IBD type and duration, colonoscopy within 1 year was associated with a lower all-cause mortality (adjusted hazard ratio, 0.56; 95% CI, 0.36-0.88). CONCLUSIONS In a national cohort of patients with CRC-IBD, colonoscopy within 3 years prior to CRC diagnosis was associated with early tumor stage at diagnosis, and colonoscopy within 1 year was associated with a reduced all-cause mortality compared with no colonoscopy. Our findings support colonoscopy intervals of 1 to 3 years in patients with IBD to reduce late-stage CRC and all-cause mortality.
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Affiliation(s)
- Hyun-Seok Kim
- Section of Gastroenterology and Hepatology, Baylor College of Medicine, Houston, Texas
| | - Ruben Hernaez
- Section of Gastroenterology and Hepatology, Baylor College of Medicine, Houston, Texas; Center for Innovations in Quality, Effectiveness and Safety (IQuESt), Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas
| | - Shubhada Sansgiry
- Center for Innovations in Quality, Effectiveness and Safety (IQuESt), Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas; Section of Health Services Research, Baylor College of Medicine, Houston, Texas
| | - Akbar K Waljee
- Division of Gastroenterology, University of Michigan, Ann Arbor, Michigan; Health Services Research and Development Center of Clinical Management Research, Veterans Administration Ann Arbor, Ann Arbor, Michigan
| | - Frank I Scott
- Division of Gastroenterology, University of Colorado, Aurora, Colorado
| | - James D Lewis
- Division of Gastroenterology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Hashem B El-Serag
- Section of Gastroenterology and Hepatology, Baylor College of Medicine, Houston, Texas; Center for Innovations in Quality, Effectiveness and Safety (IQuESt), Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas
| | - Jason K Hou
- Section of Gastroenterology and Hepatology, Baylor College of Medicine, Houston, Texas; Center for Innovations in Quality, Effectiveness and Safety (IQuESt), Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas.
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Pham C, Tomcsanyi KM, Waljee AK, Hou JK. Re: Lin I, Melsheimer R, Bhak RH, et al. Impact of switching to infliximab biosimilars on treatment patterns among US veterans receiving innovator infliximab. Curr Med Res Opin. 2022;38(4):613-627. Curr Med Res Opin 2022; 38:2241-2242. [PMID: 35972216 DOI: 10.1080/03007995.2022.2113694] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Affiliation(s)
- Codey Pham
- Department of Medicine, Baylor College of Medicine, Houston, TX, USA
| | - Kelly M Tomcsanyi
- VA Pittsburgh Healthcare System, VA Center for Medication Safety (VA MedSAFE), Pittsburgh, PA, USA
- VA Pittsburgh Healthcare System, Center for Health Equity Research and Promotion (CHERP), Pittsburgh, PA, USA
| | - Akbar K Waljee
- Health Services Research and Development Center of Clinical Management Research, VA Ann Arbor, Ann Arbor, MI, USA
- Michigan Integrated Center for Health Analytics and Medical Prediction (MiCHAMP), Ann Arbor, MI, USA
- Department of Internal Medicine, Division of Gastroenterology and Hepatology, Michigan Medicine, Ann Arbor, MI, USA
| | - Jason K Hou
- Department of Medicine, Section of Gastroenterology and Hepatology, Baylor College of Medicine, Houston, TX, USA
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Cohen-Mekelburg S, Tony Van M, Wallace B, Berinstein J, Yu X, Lewis J, Hou J, Dominitz JA, Waljee AK. The Association Between Nonsteroidal Anti-Inflammatory Drug Use and Inflammatory Bowel Disease Exacerbations: A True Association or Residual Bias? Am J Gastroenterol 2022; 117:1851-1857. [PMID: 35970816 PMCID: PMC9714642 DOI: 10.14309/ajg.0000000000001932] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2022] [Accepted: 07/07/2022] [Indexed: 01/11/2023]
Abstract
INTRODUCTION Studies suggest that nonsteroidal anti-inflammatory drugs (NSAID) may contribute to inflammatory bowel disease (IBD) exacerbations. We examined whether variation in the likelihood of IBD exacerbations is attributable to NSAID. METHODS In a cohort of patients with IBD (2004-2015), we used 3 analytic methods to examine the likelihood of an exacerbation after an NSAID exposure. First, we matched patients by propensity for NSAID use and examined the association between NSAID exposure and IBD exacerbation using an adjusted Cox proportional hazards model. To assess for residual confounding, we estimated a previous event rate ratio and used a self-controlled case series analysis to further explore the relationship between NSAID and IBD exacerbations. RESULTS We identified 15,705 (44.8%) and 19,326 (55.2%) IBD patients with and without an NSAID exposure, respectively. Findings from the Cox proportional hazards model suggested an association between NSAID and IBD exacerbation (hazard ratio 1.24; 95% confidence interval 1.16-1.33). However, the likelihood of an IBD exacerbation in the NSAID-exposed arm preceding NSAID exposure was similar (hazard ratio 1.30; 95% confidence interval 1.21-1.39). A self-controlled case series analysis of 3,968 patients who had both an NSAID exposure and IBD exacerbation demonstrated similar exacerbation rates in the 1 year preceding exposure, 2-6 weeks postexposure, and 6 weeks to 6 months postexposure, but a higher incidence in 0-2 weeks postexposure, suggesting potential confounding by reverse causality. DISCUSSION While we see an association between NSAID and IBD exacerbations using traditional methods, further analysis suggests this may be secondary to residual bias. These findings may reassure patients and clinicians considering NSAID as a nonopioid pain management option.
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Affiliation(s)
- Shirley Cohen-Mekelburg
- Division of Gastroenterology and Hepatology, University of Michigan Medicine, Ann Arbor, MI
- VA Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI
| | - M.S. Tony Van
- VA Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI
| | - Beth Wallace
- VA Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI
- Division of Rheumatology, University of Michigan Medicine, Ann Arbor, MI
| | - Jeff Berinstein
- Division of Gastroenterology and Hepatology, University of Michigan Medicine, Ann Arbor, MI
| | - Xianshi Yu
- Department of Statistics, University of Michigan, Ann Arbor, MI
| | - James Lewis
- Division of Gastroenterology and Hepatology, University of Pennsylvania, Philadelphia, PA
| | - Jason Hou
- Division of Gastroenterology and Hepatology, Baylor College of Medicine, Houston, TX
- VA Houston Healthcare System, Houston, TX
| | - Jason A. Dominitz
- VA Puget Sound Healthcare System, Seattle, WA
- Division of Gastroenterology and Hepatology, University of Washington, Seattle, WA
| | - Akbar K. Waljee
- Division of Gastroenterology and Hepatology, University of Michigan Medicine, Ann Arbor, MI
- VA Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI
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Irfan FB, Minetti R, Telford B, Ahmed FS, Syed AY, Hollon N, Brauman SC, Cunningham W, Awad ME, Saleh KJ, Waljee AK, Brusselaers N. Coronavirus pandemic in the Nordic countries: Health policy and economy trade-off. J Glob Health 2022; 12:05017. [PMID: 35932219 PMCID: PMC9356530 DOI: 10.7189/jogh.12.05017] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Background Countries making up the Nordic region – Denmark, Finland, Iceland, Norway, and Sweden – have minimal socioeconomic, cultural, and geographical differences between them, allowing for a fair comparative analysis of the health policy and economy trade-off in their national approaches towards mitigating the impact of the COVID-19 pandemic. Methods This study utilized publicly available COVID-19 data of the Nordic countries from January 2020 to January 3, 2021. COVID-19 epidemiology, public health and health policy, health system capacity, and macroeconomic data were analysed for each Nordic country. Joinpoint regression analysis was performed to identify changes in temporal trends using average monthly percent change (AMPC) and average weekly percent change (AWPC). Results Sweden’s health policy, being by far the most relaxed response to COVID-19, was found to have the largest COVID-19 incidence and mortality, and the highest AWPC increases for both indicators (13.5, 95% CI = 5.6, 22.0, P < 0.001; 6.3, 95% CI = 3.5, 9.1, P < 0.001). Denmark had the highest number of COVID-19 tests per capita, consistent with their approach of increased testing as a preventive strategy for disease transmission. Iceland had the second-highest number of tests per capita due to their mass-testing, contact tracing, quarantine and isolation response. Only Norway had a significant increase in unemployment (AMPC = 2.8%, 95% CI = 0.7-4.9, P < 0.009) while the percentage change in real Gross Domestic Product (GDP) was insignificant for all countries. Conclusions There was no trade-off between public health policy and economy during the COVID-19 pandemic in the Nordic region. Sweden’s relaxed and delayed COVID-19 health policy response did not benefit the economy in the short term, while leading to disproportionate COVID-19 hospitalizations and mortality.
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Affiliation(s)
- Furqan B Irfan
- Institute of Global Health, Michigan State University, East Lansing, Michigan, USA.,Department of Neurology and Ophthalmology, College of Osteopathic Medicine, Michigan State University, East Lansing, Michigan, USA
| | - Raoul Minetti
- Department of Economics, Michigan State University, Marshall-Adams Hall, East Lansing, Michigan, USA
| | - Ben Telford
- College of Osteopathic Medicine, Michigan State University, East Lansing, Michigan, USA
| | - Fahad S Ahmed
- Department of Pathology, Wayne State University, Detroit, Michigan, USA
| | | | - Nick Hollon
- College of Osteopathic Medicine, Michigan State University, East Lansing, Michigan, USA
| | - Seth C Brauman
- College of Osteopathic Medicine, Michigan State University, East Lansing, Michigan, USA
| | - William Cunningham
- Institute of Global Health, Michigan State University, East Lansing, Michigan, USA
| | - Mohamed E Awad
- College of Osteopathic Medicine, Michigan State University, East Lansing, Michigan, USA
| | - Khaled J Saleh
- College of Osteopathic Medicine, Michigan State University, East Lansing, Michigan, USA
| | - Akbar K Waljee
- University of Michigan Medical School, Institute for Healthcare Policy and Innovation, Ann Arbor, Michigan, USA.,University of Michigan Medical School, Department of Internal Medicine, Division of Gastroenterology and Hepatology, Ann Arbor, Michigan, USA
| | - Nele Brusselaers
- Centre for Translational Microbiome Research, Department of Microbiology, Tumour and Cell Biology, Karolinska Institutet, Stockholm, Sweden.,Global Health Institute, Antwerp University, Antwerpen, Wilrijk, Belgium
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32
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Singal AG, Chen Y, Sridhar S, Mittal V, Fullington H, Shaik M, Waljee AK, Tiro J. Novel Application of Predictive Modeling: A Tailored Approach to Promoting HCC Surveillance in Patients With Cirrhosis. Clin Gastroenterol Hepatol 2022; 20:1795-1802.e2. [PMID: 33662594 PMCID: PMC9048842 DOI: 10.1016/j.cgh.2021.02.038] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2020] [Revised: 02/16/2021] [Accepted: 02/22/2021] [Indexed: 02/07/2023]
Abstract
OBJECTIVE There has been increased interest in interventions to promote hepatocellular carcinoma (HCC) surveillance given low utilization and high proportions of late stage detection. Accurate prediction of patients likely versus unlikely to respond to interventions could allow a cost-effective approach to outreach and facilitate targeting more intensive interventions to likely non-responders. DESIGN We conducted a secondary analysis of a randomized clinical trial evaluating a mailed outreach strategy to promote HCC surveillance among 1200 cirrhosis patients at a safety-net health system between December 2014 and March 2017. We developed regularized logistic regression (RLR) and gradient boosting machine (GBM) algorithm models to predict surveillance completion during each of the 3 screening rounds in a training set (n = 960). Model performance was assessed using multiple performance metrics in an independent test set (n = 240). RESULTS Among 1200 patients, surveillance was completed in 41-47% of patients over the three rounds. The RLR and GBM models demonstrated good discriminatory accuracy, with area under receiver operating characteristic (AUROC) curves of 0.67 and 0.66 respectively in the first surveillance round and improved to 0.77 by the third surveillance round after incorporating prior screening behavior as a feature. Additional performance characteristics including the Brier score, Hosmer-Lemeshow test and reliability diagrams were also evaluated. The most important variables for the predictive model were prior screening completion status and past primary care contact. CONCLUSIONS Predictive models can help stratify patients' likelihood to respond to surveillance outreach invitations, facilitating tailored strategies to maximize effectiveness and cost-effectiveness of HCC surveillance population health programs.
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Affiliation(s)
- Amit G. Singal
- Department of Internal Medicine, University of Texas Southwestern Medical Center and Parkland Health & Hospital, Dallas, Texas,Department of Population Sciences, University of Texas Southwestern Medical Center and Parkland Health & Hospital, Dallas, Texas,Harold C. Simmons Cancer Center, University of Texas Southwestern Medical Center and Parkland Health & Hospital, Dallas, Texas
| | - Yixing Chen
- Mendoza College of Business, University of Notre Dame, Notre Dame, Indiana
| | - Shrihari Sridhar
- Mays Business School, Texas A&M University, College Station, Texas
| | - Vikas Mittal
- Jones Graduate School of Business, Rice University, Houston, Texas
| | - Hannah Fullington
- Department of Population Sciences, University of Texas Southwestern Medical Center and Parkland Health & Hospital, Dallas, Texas
| | - Muzeeb Shaik
- Mays Business School, Texas A&M University, College Station, Texas
| | - Akbar K. Waljee
- Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan,VA Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, Michigan,Michigan Integrated Center for Health Analytics and Medical Prediction (MiCHAMP), Ann Arbor, Michigan
| | - Jasmin Tiro
- Department of Population Sciences, University of Texas Southwestern Medical Center and Parkland Health & Hospital, Dallas, Texas,Harold C. Simmons Cancer Center, University of Texas Southwestern Medical Center and Parkland Health & Hospital, Dallas, Texas
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Singal AG, Zhang E, Narasimman M, Rich NE, Waljee AK, Hoshida Y, Yang JD, Reig M, Cabibbo G, Nahon P, Parikh ND, Marrero JA. HCC surveillance improves early detection, curative treatment receipt, and survival in patients with cirrhosis: A meta-analysis. J Hepatol 2022; 77:128-139. [PMID: 35139400 PMCID: PMC9232881 DOI: 10.1016/j.jhep.2022.01.023] [Citation(s) in RCA: 125] [Impact Index Per Article: 62.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2021] [Revised: 01/20/2022] [Accepted: 01/24/2022] [Indexed: 02/06/2023]
Abstract
BACKGROUND & AIMS There is controversy regarding the overall value of hepatocellular carcinoma (HCC) surveillance in patients with cirrhosis given the lack of data from randomized-controlled trials. To address this issue, we conducted a systematic review and meta-analysis of cohort studies evaluating the benefits and harms of HCC surveillance in patients with cirrhosis. METHODS We performed a search of the Medline and EMBASE databases and national meeting abstracts from January 2014 through July 2020 for studies reporting early-stage HCC detection, curative treatment receipt, or overall survival, stratified by HCC surveillance status, among patients with cirrhosis. Pooled risk ratios (RRs) and hazard ratios, according to HCC surveillance status, were calculated for each outcome using the DerSimonian and Laird method for random effects models. RESULTS We identified 59 studies including 145,396 patients with HCC, which was detected by surveillance in 41,052 (28.2%) cases. HCC surveillance was associated with improved early-stage detection (RR 1.86, 95% CI 1.73-1.98; I2 = 82%), curative treatment receipt (RR 1.83, 95% CI 1.69-1.97; I2 = 75%), and overall survival (hazard ratio 0.67, 95% CI 0.61-0.72; I2 = 78%) after adjusting for lead-time bias; however, there was notable heterogeneity in all pooled estimates. Four studies examined surveillance-related physical harms due to false positive or indeterminate surveillance results, but no studies examined potential financial or psychological harms. The proportion of patients experiencing surveillance-related physical harms ranged from 8.8% to 27.5% across studies, although most harms were mild in severity. CONCLUSION HCC surveillance is associated with improved early detection, curative treatment receipt, and survival in patients with cirrhosis, although there was heterogeneity in pooled estimates. Available data suggest HCC surveillance is of high value in patients with cirrhosis, although continued rigorous studies evaluating benefits and harms are still needed. LAY SUMMARY There has been ongoing debate about the overall value of hepatocellular carcinoma (HCC) screening in patients with cirrhosis given the lack of data from randomized-controlled trials. In a systematic review of contemporary cohort studies, we found that HCC screening is associated with improved early detection, curative treatment receipt, and survival in patients with cirrhosis, although there were fewer data quantifying potential screening-related harms. Available data suggest HCC screening is of high value in patients with cirrhosis, although continued studies evaluating benefits and harms are still needed.
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Affiliation(s)
- Amit G Singal
- Department of Internal Medicine, UT Southwestern Medical Center, Dallas, TX, United States.
| | - Emily Zhang
- Department of Internal Medicine, UT Southwestern Medical Center, Dallas, TX, United States
| | - Manasa Narasimman
- Department of Internal Medicine, UT Southwestern Medical Center, Dallas, TX, United States
| | - Nicole E Rich
- Department of Internal Medicine, UT Southwestern Medical Center, Dallas, TX, United States
| | - Akbar K Waljee
- Department of Internal Medicine, University of Michigan, Ann Arbor MI, United States
| | - Yujin Hoshida
- Department of Internal Medicine, UT Southwestern Medical Center, Dallas, TX, United States
| | - Ju Dong Yang
- Karsh Division of Gastroenterology and Hepatology, Comprehensive Transplant Center, Samuel Oschin Comprehensive Cancer Institute, Cedars Sinai, Los Angeles, CA, United States
| | - Maria Reig
- Barcelona Clinic Liver Cancer (BCLC) Group, Hospital Clinic de Barcelona, CIBEREEHD, Barcelona University, Barcelona, Spain
| | - Giuseppe Cabibbo
- Section of Gastroenterology & Hepatology, Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties, PROMISE, University of Palermo, Palermo, Italy
| | - Pierre Nahon
- AP-HP, Hôpital Avicenne, Liver Unit, Université Sorbonne Paris Nord, Bobigny, France; Inserm, UMR-1138 Université de Paris, Paris, France
| | - Neehar D Parikh
- Department of Internal Medicine, University of Michigan, Ann Arbor MI, United States
| | - Jorge A Marrero
- Department of Internal Medicine, University of Pennsylvania, Philadelphia PA, United States
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Kurlander JE, Waljee AK, Menees SB, Lipson R, Kokaly AN, Read AJ, Shehadeh KS, Cohn A, Saini SD. Regression and Random Forest Machine Learning Have Limited Performance in Predicting Bowel Preparation in Veteran Population. Dig Dis Sci 2022; 67:2827-2841. [PMID: 34169434 DOI: 10.1007/s10620-021-07113-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/31/2020] [Accepted: 06/12/2021] [Indexed: 12/09/2022]
Abstract
BACKGROUND Inadequate bowel preparation undermines the quality of colonoscopy, but patients likely to be affected are difficult to identify beforehand. AIMS This study aimed to develop, validate, and compare prediction models for bowel preparation inadequacy using conventional logistic regression (LR) and random forest machine learning (RFML). METHODS We created a retrospective cohort of patients who underwent outpatient colonoscopy at a single VA medical center between January 2012 and October 2015. Candidate predictor variables were chosen after a literature review. We extracted all available predictor variables from the electronic medical record, and bowel preparation from the endoscopy database. The data were split into 70% training and 30% validation sets. Multivariable LR and RFML were used to predict preparation inadequacy as a dichotomous outcome. RESULTS The cohort included 6,885 Veterans, of whom 964 (14%) had inadequate preparation. Using LR, the area under the receiver operating characteristic curve (AUC) for the validation cohort was 0.66 (95% CI 0.62, 0.69) and the Brier score, in which a lower score indicates better performance, was 0.11. Using RFML, the AUC for the validation cohort was 0.61 (95% CI 0.58, 0.65) and the Brier score was 0.12. CONCLUSIONS LR and RFML had similar performance in predicting bowel preparation, which was modest and likely insufficient for use in practice. Future research is needed to identify additional predictor variables and to test other machine learning algorithms. At present, endoscopy units should focus on universal strategies to enhance preparation adequacy.
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Affiliation(s)
- Jacob E Kurlander
- Department of Internal Medicine, University of Michigan, 3912 Taubman Center, 1500 E. Medical Center Dr., SPC 5362, Ann Arbor, MI, 48109-5362, USA. .,Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, USA. .,Veterans Affairs Ann Arbor Center for Clinical Management Research, Ann Arbor, MI, USA.
| | - Akbar K Waljee
- Department of Internal Medicine, University of Michigan, 3912 Taubman Center, 1500 E. Medical Center Dr., SPC 5362, Ann Arbor, MI, 48109-5362, USA.,Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, USA.,Veterans Affairs Ann Arbor Center for Clinical Management Research, Ann Arbor, MI, USA
| | - Stacy B Menees
- Department of Internal Medicine, University of Michigan, 3912 Taubman Center, 1500 E. Medical Center Dr., SPC 5362, Ann Arbor, MI, 48109-5362, USA.,VA Ann Arbor Healthcare System, 2215 Fuller Road, Ann Arbor, MI, USA
| | - Rachel Lipson
- Veterans Affairs Ann Arbor Center for Clinical Management Research, Ann Arbor, MI, USA
| | - Alex N Kokaly
- Department of Medicine, UCLA Health, 200 UCLA Medical Plaza, Suite 420, Los Angeles, 90095-1685, CA, USA
| | - Andrew J Read
- Department of Internal Medicine, University of Michigan, 3912 Taubman Center, 1500 E. Medical Center Dr., SPC 5362, Ann Arbor, MI, 48109-5362, USA.,Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, USA
| | - Karmel S Shehadeh
- Department of Industrial and Systems Engineering, Lehigh University, 200 West Packer Ave, Bethlehem, PA, 18015, USA
| | - Amy Cohn
- Department of Industrial and Operations Engineering, University of Michigan, 2015 Beal Ave, Ann Arbor, MI, 4819-2117, USA
| | - Sameer D Saini
- Department of Internal Medicine, University of Michigan, 3912 Taubman Center, 1500 E. Medical Center Dr., SPC 5362, Ann Arbor, MI, 48109-5362, USA.,Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, USA.,Veterans Affairs Ann Arbor Center for Clinical Management Research, Ann Arbor, MI, USA
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Waljee AK, Weinheimer-Haus EM, Abubakar A, Ngugi AK, Siwo GH, Kwakye G, Singal AG, Rao A, Saini SD, Read AJ, Baker JA, Balis U, Opio CK, Zhu J, Saleh MN. Artificial intelligence and machine learning for early detection and diagnosis of colorectal cancer in sub-Saharan Africa. Gut 2022; 71:1259-1265. [PMID: 35418482 PMCID: PMC9177787 DOI: 10.1136/gutjnl-2022-327211] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2022] [Accepted: 03/17/2022] [Indexed: 01/05/2023]
Affiliation(s)
- Akbar K Waljee
- Veterans Affairs Center for Clinical Management Research, Ann Arbor, Michigan, USA .,Department of Internal Medicine, Division of Gastroenterology, University of Michigan, Ann Arbor, Michigan, USA.,Center for Global Health Equity, University of Michigan, Ann Arbor, Michigan, USA.,Michigan Integrated Center for Health Analytics and Medical Prediction (MiCHAMP), University of Michigan, Ann Arbor, Michigan, USA
| | - Eileen M Weinheimer-Haus
- Department of Internal Medicine, Division of Gastroenterology, University of Michigan, Ann Arbor, Michigan, USA,Center for Global Health Equity, University of Michigan, Ann Arbor, Michigan, USA,Michigan Integrated Center for Health Analytics and Medical Prediction (MiCHAMP), University of Michigan, Ann Arbor, Michigan, USA
| | - Amina Abubakar
- Institute for Human Development, The Aga Khan University, Nairobi, Kenya
| | - Anthony K Ngugi
- Department of Population Health, The Aga Khan University, Nairobi, Kenya
| | - Geoffrey H Siwo
- Department of Internal Medicine, Division of Gastroenterology, University of Michigan, Ann Arbor, Michigan, USA,Center for Global Health Equity, University of Michigan, Ann Arbor, Michigan, USA,Eck Institute for Global Health, University of Notre Dame, South Bend, Indiana, USA,Center for Research Computing, University of Notre Dame, South Bend, Indiana, USA
| | - Gifty Kwakye
- Department of Surgery, Division of Colorectal Surgery, University of Michigan, Ann Arbor, Michigan, USA
| | - Amit G Singal
- Harold C. Simmons Comprehensive Cancer Center, The University of Texas Southwestern Medical Center, Dallas, Texas, USA,Department of Internal Medicine, Division of Digestive and Liver Diseases, The University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Arvind Rao
- Michigan Integrated Center for Health Analytics and Medical Prediction (MiCHAMP), University of Michigan, Ann Arbor, Michigan, USA,Department of Computational Medicine and Bioinformatics, University of Michigan, Ann Arbor, Michigan, USA,Department of Biomedical Engineering, University of Michigan, Ann Arbor, Michigan, USA,Department of Radiation Oncology, University of Michigan, Ann Arbor, Michigan, USA
| | - Sameer D Saini
- Veterans Affairs Center for Clinical Management Research, Ann Arbor, Michigan, USA,Department of Internal Medicine, Division of Gastroenterology, University of Michigan, Ann Arbor, Michigan, USA
| | - Andrew J Read
- Department of Internal Medicine, Division of Gastroenterology, University of Michigan, Ann Arbor, Michigan, USA,Michigan Integrated Center for Health Analytics and Medical Prediction (MiCHAMP), University of Michigan, Ann Arbor, Michigan, USA
| | - Jessica A Baker
- Veterans Affairs Center for Clinical Management Research, Ann Arbor, Michigan, USA,Center for Global Health Equity, University of Michigan, Ann Arbor, Michigan, USA,Michigan Integrated Center for Health Analytics and Medical Prediction (MiCHAMP), University of Michigan, Ann Arbor, Michigan, USA
| | - Ulysses Balis
- Department of Pathology, University of Michigan Health System, Ann Arbor, Michigan, USA
| | - Christopher K Opio
- Department of Medicine, Aga Khan University Hospital Nairobi, Nairobi, Kenya
| | - Ji Zhu
- Center for Global Health Equity, University of Michigan, Ann Arbor, Michigan, USA,Michigan Integrated Center for Health Analytics and Medical Prediction (MiCHAMP), University of Michigan, Ann Arbor, Michigan, USA,Department of Statistics, University of Michigan, Ann Arbor, Michigan, USA
| | - Mansoor N Saleh
- O'Neal Comprehensive Cancer Center, The University of Alabama at Birmingham, Birmingham, Alabama, USA,Department of Hematology-Oncology, Aga Khan University Hospital Nairobi, Nairobi, Kenya
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Stidham RW, Vickers AJ, Singh K, Waljee AK. From clinical trials to clinical practice: how should we design and evaluate prediction models in the care of IBD? Gut 2022; 71:1046-1047. [PMID: 34686576 PMCID: PMC9023586 DOI: 10.1136/gutjnl-2021-324712] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2021] [Accepted: 05/12/2021] [Indexed: 12/08/2022]
Affiliation(s)
- Ryan W. Stidham
- Division of Gastroenterology, Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, Michigan, USA,Department of Computational Medicine and Bioinformatics, University of Michigan Medical School, Ann Arbor, Michigan, USA,Michigan Integrated Center for Health Analytics and Medical Prediction (MiCHAMP), Ann Arbor, Michigan, USA
| | - Andrew J. Vickers
- Department of Epidemiology and Biostatistics, Memorial Sloan-Kettering Cancer Center, New York, NY 10021, USA
| | - Karandeep Singh
- Michigan Integrated Center for Health Analytics and Medical Prediction (MiCHAMP), Ann Arbor, Michigan, USA,Department of Learning Health Sciences, University of Michigan Medical School, Ann Arbor, Michigan, USA
| | - Akbar K. Waljee
- Division of Gastroenterology, Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, Michigan, USA,Michigan Integrated Center for Health Analytics and Medical Prediction (MiCHAMP), Ann Arbor, Michigan, USA,Department of Learning Health Sciences, University of Michigan Medical School, Ann Arbor, Michigan, USA,Department of Veterans Affairs Center for Clinical Management Research, Ann Arbor, Michigan, USA
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Berinstein JA, Cohen-Mekelburg SA, Greenberg GM, Wray D, Berry SK, Saini SD, Fendrick AM, Adams MA, Waljee AK, Higgins PD. A Care Coordination Intervention Improves Symptoms But Not Charges in High-Risk Patients With Inflammatory Bowel Disease. Clin Gastroenterol Hepatol 2022; 20:1029-1038.e9. [PMID: 34461298 PMCID: PMC8882693 DOI: 10.1016/j.cgh.2021.08.034] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2021] [Revised: 08/17/2021] [Accepted: 08/23/2021] [Indexed: 02/07/2023]
Abstract
BACKGROUND Inflammatory bowel disease (IBD) is associated with substantial symptom burden, variability in clinical outcomes, and high direct costs. We sought to determine if a care coordination-based strategy was effective at improving patient symptom burden and reducing healthcare costs for patients with IBD in the top quintile of predicted healthcare utilization and costs. METHODS We performed a randomized controlled trial to evaluate the efficacy of a patient-tailored multicomponent care coordination intervention composed of proactive symptom monitoring and care coordinator-triggered algorithms. Enrolled patients with IBD were randomized to usual care or to our care coordination intervention over a 9-month period (April 2019 to January 2020). Primary outcomes included change in patient symptom scores throughout the intervention and IBD-related charges at 12 months. RESULTS Eligible IBD patients in the top quintile for predicted healthcare utilization and expenditures were identified. A total of 205 patients were enrolled and randomized to our intervention (n = 100) or to usual care (n = 105). Patients in the care coordinator arm demonstrated an improvement in symptoms scores compared with usual care (coefficient, -0.68, 95% confidence interval, -1.18 to -0.18; P = .008) without a significant difference in median annual IBD-related healthcare charges ($10,094 vs $9080; P = .322). CONCLUSIONS In this first randomized controlled trial of a patient-tailored care coordination intervention, composed of proactive symptom monitoring and care coordinator-triggered algorithms, we observed an improvement in patient symptom scores but not in healthcare charges. Care coordination programs may represent an effective value-based approach to improve symptoms scores without added direct costs in a subgroup of high-risk patients with IBD. (ClinicalTrials.gov, Number: NCT04796571).
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Affiliation(s)
- Jeffrey A. Berinstein
- Division of Gastroenterology and Hepatology, Michigan Medicine, Ann Arbor, MI, USA.,Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, USA
| | - Shirley A. Cohen-Mekelburg
- Division of Gastroenterology and Hepatology, Michigan Medicine, Ann Arbor, MI, USA.,Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, USA,VA Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI, USA
| | | | - Daniel Wray
- Twine Clinical Consulting, LLC Park City, UT, USA
| | - Sameer K. Berry
- Division of Gastroenterology and Hepatology, Michigan Medicine, Ann Arbor, MI, USA
| | - Sameer D. Saini
- Division of Gastroenterology and Hepatology, Michigan Medicine, Ann Arbor, MI, USA.,Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, USA,VA Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI, USA
| | - A. Mark Fendrick
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, USA,Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA,Center for Value-Based Insurance Design, University of Michigan, Ann Arbor, MI, USA
| | - Megan A. Adams
- Division of Gastroenterology and Hepatology, Michigan Medicine, Ann Arbor, MI, USA.,Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, USA,VA Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI, USA
| | - Akbar K. Waljee
- Division of Gastroenterology and Hepatology, Michigan Medicine, Ann Arbor, MI, USA.,Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, USA,VA Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI, USA
| | - Peter D.R. Higgins
- Division of Gastroenterology and Hepatology, Michigan Medicine, Ann Arbor, MI, USA
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Rubenstein JH, Evans RR, Burns JA, Arasim ME, Zhu J, Waljee AK, Macdonald PW, Adams MA, Chang JW, Firsht EM, Hawley ST, Saini SD, Wallner LP. Patients With Adenocarcinoma of the Esophagus or Esophagogastric Junction Frequently Have Potential Screening Opportunities. Gastroenterology 2022; 162:1349-1351.e5. [PMID: 34942170 PMCID: PMC8934293 DOI: 10.1053/j.gastro.2021.12.255] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2021] [Revised: 12/14/2021] [Accepted: 12/16/2021] [Indexed: 12/02/2022]
Affiliation(s)
- Joel H. Rubenstein
- Veterans Affairs Center for Clinical Management Research, LTC Charles S. Kettles Veterans Affairs Medical Center, Ann Arbor, MI,Division of Gastroenterology, Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, MI,Rogel Cancer Center, University of Michigan Medical School, Ann Arbor, MI,Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI
| | - Richard R. Evans
- Veterans Affairs Center for Clinical Management Research, LTC Charles S. Kettles Veterans Affairs Medical Center, Ann Arbor, MI
| | - Jennifer A. Burns
- Veterans Affairs Center for Clinical Management Research, LTC Charles S. Kettles Veterans Affairs Medical Center, Ann Arbor, MI
| | - Maria E. Arasim
- Veterans Affairs Center for Clinical Management Research, LTC Charles S. Kettles Veterans Affairs Medical Center, Ann Arbor, MI
| | - Ji Zhu
- Department of Statistics, University of Michigan College of Literature, Science, and Arts, Ann Arbor, MI
| | - Akbar K. Waljee
- Veterans Affairs Center for Clinical Management Research, LTC Charles S. Kettles Veterans Affairs Medical Center, Ann Arbor, MI,Division of Gastroenterology, Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, MI,Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI
| | | | - Peter W Macdonald
- Department of Statistics, University of Michigan College of Literature, Science, and Arts, Ann Arbor, MI
| | - Megan A Adams
- Veterans Affairs Center for Clinical Management Research, LTC Charles S. Kettles Veterans Affairs Medical Center, Ann Arbor, MI; Division of Gastroenterology, Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, MI; Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI
| | - Joy W Chang
- Division of Gastroenterology, Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, MI
| | - Elizabeth M Firsht
- Veterans Affairs Center for Clinical Management Research, LTC Charles S. Kettles Veterans Affairs Medical Center, Ann Arbor, MI
| | - Sarah T Hawley
- Veterans Affairs Center for Clinical Management Research, LTC Charles S. Kettles Veterans Affairs Medical Center, Ann Arbor, MI; Rogel Cancer Center, University of Michigan Medical School, Ann Arbor, MI; Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI; Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, MI
| | - Sameer D Saini
- Veterans Affairs Center for Clinical Management Research, LTC Charles S. Kettles Veterans Affairs Medical Center, Ann Arbor, MI; Division of Gastroenterology, Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, MI; Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI
| | - Lauren P Wallner
- Rogel Cancer Center, University of Michigan Medical School, Ann Arbor, MI; Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI; Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, MI
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Read AJ, Rice MD, Baker JR, Waljee AK, Saini SD. Diffusion of an innovation: growth in video capsule endoscopy in the U.S. Medicare population from 2003 to 2019. BMC Health Serv Res 2022; 22:425. [PMID: 35361221 PMCID: PMC8969398 DOI: 10.1186/s12913-022-07780-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2021] [Accepted: 03/15/2022] [Indexed: 11/12/2022] Open
Abstract
Background Video capsule endoscopy (VCE), approved by the U.S. Food and Drug Administration (FDA) in 2001, represented a disruptive technology that transformed evaluation of the small intestine. Adoption of this technology over time and current use within the U.S. clinical population has not been well described. Methods To assess the growth of capsule endoscopy within the U.S. Medicare provider population (absolute growth and on a population-adjusted basis), characterize the providers performing VCE, and describe potential regional differences in use. Medicare summary data from 2003 to 2019 were used to retrospectively analyze capsule endoscopy use in a multiple cross-sectional design. In addition, detailed provider summary files were used from 2012 to 2018 to characterize provider demographics. Results VCE use grew rapidly from 2003 to 2008 followed by a plateau from 2008 to 2019. There was significant variation in use of VCE between states, with up to 10-fold variation between states (14.6 to 156.1 per 100,000 enrollees in 2018). During this time, the adjusted VCE use on a population-adjusted basis declined, reflecting saturation of growth. Conclusions Growth of VCE use over time follows an S-shaped diffusion of innovation curve demonstrating a successful diffusion of innovation within gastroenterology. The lack of additional growth since 2008 suggests that current levels of use are well matched to overall population need within the constraints of reimbursement. Future studies should examine whether this lack of growth has implications for access and healthcare inequities. Supplementary Information The online version contains supplementary material available at 10.1186/s12913-022-07780-2.
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Affiliation(s)
- Andrew J Read
- Division of Gastroenterology and Hepatology, University of Michigan, Ann Arbor, MI, USA. .,Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, USA.
| | - Michael D Rice
- Division of Gastroenterology and Hepatology, University of Michigan, Ann Arbor, MI, USA
| | - Jason R Baker
- Atrium Health, Carolinas Medical Center, Charlotte, NC, USA
| | - Akbar K Waljee
- Division of Gastroenterology and Hepatology, University of Michigan, Ann Arbor, MI, USA.,Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, USA.,VA HSR&D Center for Clinical Management Research, Ann Arbor, MI, USA
| | - Sameer D Saini
- Division of Gastroenterology and Hepatology, University of Michigan, Ann Arbor, MI, USA.,Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, USA.,VA HSR&D Center for Clinical Management Research, Ann Arbor, MI, USA
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40
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Oselio B, Singal AG, Zhang X, Van T, Liu B, Zhu J, Waljee AK. Reinforcement learning evaluation of treatment policies for patients with hepatitis C virus. BMC Med Inform Decis Mak 2022; 22:63. [PMID: 35272662 PMCID: PMC8913329 DOI: 10.1186/s12911-022-01789-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2021] [Accepted: 02/22/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Evaluation of new treatment policies is often costly and challenging in complex conditions, such as hepatitis C virus (HCV) treatment, or in limited-resource settings. We sought to identify hypothetical policies for HCV treatment that could best balance the prevention of cirrhosis while preserving resources (financial or otherwise). METHODS The cohort consisted of 3792 HCV-infected patients without a history of cirrhosis or hepatocellular carcinoma at baseline from the national Veterans Health Administration from 2015 to 2019. To estimate the efficacy of hypothetical treatment policies, we utilized historical data and reinforcement learning to allow for greater flexibility when constructing new HCV treatment strategies. We tested and compared four new treatment policies: a simple stepwise policy based on Aspartate Aminotransferase to Platelet Ratio Index (APRI), a logistic regression based on APRI, a logistic regression on multiple longitudinal and demographic indicators that were prespecified for clinical significance, and a treatment policy based on a risk model developed for HCV infection. RESULTS The risk-based hypothetical treatment policy achieved the lowest overall risk with a score of 0.016 (90% CI 0.016, 0.019) while treating the most high-risk (346.4 ± 1.4) and the fewest low-risk (361.0 ± 20.1) patients. Compared to hypothetical treatment policies that treated approximately the same number of patients (1843.7 vs. 1914.4 patients), the risk-based policy had more untreated time per patient (7968.4 vs. 7742.9 patient visits), signaling cost reduction for the healthcare system. CONCLUSIONS Off-policy evaluation strategies are useful to evaluate hypothetical treatment policies without implementation. If a quality risk model is available, risk-based treatment strategies can reduce overall risk and prioritize patients while reducing healthcare system costs.
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Affiliation(s)
- Brandon Oselio
- Department of Biostatistics, University of Michigan, Ann Arbor, MI USA
| | - Amit G. Singal
- Department of Internal Medicine, Division of Digestive and Liver Diseases, UT Southwestern Medical Center, Dallas, TX USA
| | - Xuefei Zhang
- Department of Statistics, University of Michigan, Ann Arbor, MI USA
| | - Tony Van
- Health Services Research and Development Center of Clinical Management Research, VA Ann Arbor Healthcare System, 2215 Fuller Road, Gastroenterology 111D, Ann Arbor, MI 48105 USA
| | - Boang Liu
- Department of Statistics, University of Michigan, Ann Arbor, MI USA
- Googleplex, 1600 Amphitheatre Parkway, Mountainview, CA USA
| | - Ji Zhu
- Department of Statistics, University of Michigan, Ann Arbor, MI USA
- Michigan Integrated Center for Health Analytics and Medical Prediction (MiCHAMP), Ann Arbor, MI USA
| | - Akbar K. Waljee
- Health Services Research and Development Center of Clinical Management Research, VA Ann Arbor Healthcare System, 2215 Fuller Road, Gastroenterology 111D, Ann Arbor, MI 48105 USA
- Michigan Integrated Center for Health Analytics and Medical Prediction (MiCHAMP), Ann Arbor, MI USA
- Department of Internal Medicine, Division of Gastroenterology and Hepatology, Michigan Medicine, Ann Arbor, MI USA
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Ramrakhiani NS, Chen VL, Le M, Yeo YH, Barnett SD, Waljee AK, Zhu J, Nguyen MH. Optimizing hepatitis B virus screening in the United States using a simple demographics-based model. Hepatology 2022; 75:430-437. [PMID: 34496066 DOI: 10.1002/hep.32142] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2021] [Revised: 07/20/2021] [Accepted: 08/27/2021] [Indexed: 12/12/2022]
Abstract
BACKGROUND AND AIMS Chronic hepatitis B (CHB) affects >290 million persons globally, and only 10% have been diagnosed, presenting a severe gap that must be addressed. We developed logistic regression (LR) and machine learning (ML; random forest) models to accurately identify patients with HBV, using only easily obtained demographic data from a population-based data set. APPROACH AND RESULTS We identified participants with data on HBsAg, birth year, sex, race/ethnicity, and birthplace from 10 cycles of the National Health and Nutrition Examination Survey (1999-2018) and divided them into two cohorts: training (cycles 2, 3, 5, 6, 8, and 10; n = 39,119) and validation (cycles 1, 4, 7, and 9; n = 21,569). We then developed and tested our two models. The overall cohort was 49.2% male, 39.7% White, 23.2% Black, 29.6% Hispanic, and 7.5% Asian/other, with a median birth year of 1973. In multivariable logistic regression, the following factors were associated with HBV infection: birth year 1991 or after (adjusted OR [aOR], 0.28; p < 0.001); male sex (aOR, 1.49; p = 0.0080); Black and Asian/other versus White (aOR, 5.23 and 9.13; p < 0.001 for both); and being USA-born (vs. foreign-born; aOR, 0.14; p < 0.001). We found that the ML model consistently outperformed the LR model, with higher area under the receiver operating characteristic values (0.83 vs. 0.75 in validation cohort; p < 0.001) and better differentiation of high- and low-risk persons. CONCLUSIONS Our ML model provides a simple, targeted approach to HBV screening, using only easily obtained demographic data.
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Affiliation(s)
- Nathan S Ramrakhiani
- Division of Gastroenterology and HepatologyStanford University Medical CenterPalo AltoCaliforniaUSA
| | - Vincent L Chen
- Division of Gastroenterology and HepatologyUniversity of MichiganAnn ArborMichiganUSA
| | - Michael Le
- Division of Gastroenterology and HepatologyStanford University Medical CenterPalo AltoCaliforniaUSA
| | - Yee Hui Yeo
- Division of Gastroenterology and HepatologyStanford University Medical CenterPalo AltoCaliforniaUSA.,Division of General Internal MedicineCedars-Sinai Medical CenterLos AngelesCaliforniaUSA
| | - Scott D Barnett
- Division of Gastroenterology and HepatologyStanford University Medical CenterPalo AltoCaliforniaUSA
| | - Akbar K Waljee
- Division of Gastroenterology and HepatologyUniversity of MichiganAnn ArborMichiganUSA.,Division of Gastroenterology and HepatologyVeterans Affairs Ann Arbor Health SystemAnn ArborMichiganUSA
| | - Ji Zhu
- Department of StatisticsUniversity of MichiganAnn ArborMichiganUSA
| | - Mindie H Nguyen
- Division of Gastroenterology and HepatologyStanford University Medical CenterPalo AltoCaliforniaUSA.,Department of Epidemiology and Population HealthStanford University Medical CenterPalo AltoCaliforniaUSA
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Tapper EB, Kenney B, Nikirk S, Levine DA, Waljee AK. Animal Naming Test Is Associated With Poor Patient-Reported Outcomes and Frailty in People With and Without Cirrhosis: A Prospective Cohort Study. Clin Transl Gastroenterol 2022; 13:e00447. [PMID: 35080516 PMCID: PMC8806368 DOI: 10.14309/ctg.0000000000000447] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2021] [Accepted: 12/06/2021] [Indexed: 11/17/2022] Open
Abstract
INTRODUCTION Cognitive dysfunction is a major driver of care complexity, poor patient-reported outcomes, and frailty for people with cirrhosis. The performance and clinical associations of the animal naming test (ANT) in the general population are unknown. We evaluated ANT performance in a representative sample of older Americans with and without chronic liver disease (CLD). METHODS We analyzed 6,661 subjects enrolled in the 2010-2016 Health and Retirement Survey, a representative cohort of >30,000 US adults. Average age of participants was 75 years. We evaluated 3 subject subgroups: (i) without CLD, (ii) noncirrhosis CLD, and (iii) cirrhosis. We determined the association between the ANT (overall) and S-ANT1 <10 (adjusted for age and education) and health status, basic and instrumental activities of daily living, healthcare utilization (care hours received and hospitalizations), and frailty measures (hand grip and walk speed). RESULTS Overall, 8.2% of the sample had noncirrhotic CLD and 1.3% had cirrhosis. CLD or cirrhosis was not independently associated with ANT. Poor ANT performance was associated with poor health status and frailty overall. An S-ANT <10 was associated with fair-poor self-reported health (odds ratio [OR] 1.37; 95% confidence interval [CI]: 1.20-1.56), care hours received (incidence rate ratio [IRR] 2.39; 95% CI: 1.79-3.19), and hospitalizations (IRR 1.14; 95% CI: 1.03-1.26). S-ANT <10 was also associated with activities of daily living disability (OR 1.31; 95% CI: 1.13-1.51), instrumental activities of daily living disability (OR 1.85; 95% CI: 1.59-2.14), weaker hand grip (IRR 0.94; 95% CI: 0.92-0.96), and time to walk 2.5 m (IRR 1.23; 95% CI: 1.17-1.29). DISCUSSION ANT performance is not specific to CLD/cirrhosis but is associated with patient-reported outcomes and frailty in a nationally representative sample of elderly subjects with and without CLD.
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Affiliation(s)
- Elliot B. Tapper
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Brooke Kenney
- Center for Clinical Management Research, Veterans Affairs Ann Arbor Health System, Ann Arbor, Michigan, USA
| | - Samantha Nikirk
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Deborah A. Levine
- Division of General Medicine, Department of Internal Medicine and Cognitive Health Services Research Program, University of Michigan (U-M), Ann Arbor, Michigan, USA
| | - Akbar K. Waljee
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
- Center for Clinical Management Research, Veterans Affairs Ann Arbor Health System, Ann Arbor, Michigan, USA
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Glissen Brown JR, Waljee AK, Mori Y, Sharma P, Berzin TM. Charting a path forward for clinical research in artificial intelligence and gastroenterology. Dig Endosc 2022; 34:4-12. [PMID: 33715244 DOI: 10.1111/den.13974] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2021] [Revised: 03/02/2021] [Accepted: 03/11/2021] [Indexed: 12/12/2022]
Abstract
Gastroenterology has been an early leader in bridging the gap between artificial intelligence (AI) model development and clinical trial validation, and in recent years we have seen the publication of several randomized clinical trials examining the role of AI in gastroenterology. As AI applications for clinical medicine advance rapidly, there is a clear need for guidance surrounding AI-specific study design, evaluation, comparison, analysis and reporting of results. Several initiatives are in the publication or pre-publication phase including AI-specific amendments to minimum reporting guidelines for clinical trials, society task force initiatives aimed at priority use cases and research priorities, and minimum reporting guidelines that guide the reporting of clinical prediction models. In this paper, we examine applications of AI in clinical trials and discuss elements of newly published AI-specific extensions to the Consolidated Standards of Reporting Trials and Standard Protocol Items: Recommendations for Interventional Trials statements that guide clinical trial reporting and development. We then review AI applications at the pre-trial level in both endoscopy and other subfields of gastroenterology and explore areas where further guidance is needed to supplement the current guidance available at the pre-trial level.
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Affiliation(s)
- Jeremy R Glissen Brown
- Center for Advanced Endoscopy, Division of Gastroenterology, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, USA
| | - Akbar K Waljee
- Division of Gastroenterology, University of Michigan Health System, University of Michigan, Ann Arbor, USA
| | - Yuichi Mori
- Digestive Disease Center, Showa University Northern Yokohama Hospital, Kanagawa, Japan.,Clinical Effectiveness Research Group, Institute of Health and Society, University of Oslo, Oslo, Norway
| | - Prateek Sharma
- Department of Gastroenterology and Hepatology, University of Kansas Medical Center, Kansas City, KS, USA.,Department of Gastroenterology, Kansas City VA Medical Center, Kansas City, USA
| | - Tyler M Berzin
- Center for Advanced Endoscopy, Division of Gastroenterology, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, USA
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Rego RT, Ngugi AK, Sophie Delius AJ, Luchters S, Kolars JC, Irfan FB, Weinheimer-Haus E, Abubakar A, Shah R, Zhu J, Boulton ML, Hofer T, Waljee AK. COVID-19 vaccine hesitancy among non-refugees and refugees in Kenya. PLOS Glob Public Health 2022; 2:e0000917. [PMID: 36962839 PMCID: PMC10021684 DOI: 10.1371/journal.pgph.0000917] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/17/2021] [Accepted: 07/23/2022] [Indexed: 11/19/2022]
Abstract
Factors associated with COVID-19 vaccine hesitancy (which we define as refusal to be vaccinated when asked, resulting in delayed or non- vaccination) are poorly studied in sub-Saharan Africa and among refugees, particularly in Kenya. Using survey data from wave five (March to June 2021) of the Kenya Rapid Response Phone Survey (RRPS), a household survey representative of the population of Kenya, we estimated the self-reported rates and factors associated with vaccine hesitancy among non-refugees and refugees in Kenya. Non-refugee households were recruited through sampling of the 2015/16 Kenya Household Budget Survey and random digit dialing. Refugee households were recruited through random sampling of registered refugees. Binary response questions on misinformation and information were transformed into a scale. We performed a weighted (to be representative of the overall population of Kenya) multivariable logistic regression including interactions for refugee status, with the main outcome being if the respondent self-reported that they would not take the COVID-19 vaccine if available at no cost. We calculated the marginal effects of the various factors in the model. The weighted univariate analysis estimated that 18.0% of non-refugees and 7.0% of refugees surveyed in Kenya would not take the COVID-19 vaccine if offered at no cost. Adjusted, refugee status was associated with a -13.1[95%CI:-17.5,-8.7] percentage point difference (ppd) in vaccine hesitancy. For the both refugees and non-refugees, having education beyond the primary level, having symptoms of COVID-19, avoiding handshakes, and washing hands more often were also associated with a reduction in vaccine hesitancy. Also for both, having used the internet in the past three months was associated with a 8.1[1.4,14.7] ppd increase in vaccine hesitancy; and disagreeing that the government could be trusted in responding to COVID-19 was associated with a 25.9[14.2,37.5]ppd increase in vaccine hesitancy. There were significant interactions between refugee status and some variables (geography, food security, trust in the Kenyan government's response to COVID-19, knowing somebody with COVID-19, internet use, and TV ownership). These relationships between refugee status and certain variables suggest that programming between refugees and non-refugees be differentiated and specific to the contextual needs of each group.
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Affiliation(s)
- Ryan T Rego
- Center for Global Health Equity, Michigan Medicine, University of Michigan, Ann Arbor, Michigan, United States of America
| | - Anthony K Ngugi
- Dept. of Population Health, Aga Khan University, Nairobi, Kenya
| | | | | | - Joseph C Kolars
- Center for Global Health Equity, Michigan Medicine, University of Michigan, Ann Arbor, Michigan, United States of America
| | - Furqan B Irfan
- Institute of Global Health, Michigan State University, Lansing, Michigan, United States of America
| | - Eileen Weinheimer-Haus
- Center for Global Health Equity, Michigan Medicine, University of Michigan, Ann Arbor, Michigan, United States of America
| | - Amina Abubakar
- Institute for Human Development, Aga Khan University, Nairobi, Kenya
| | - Reena Shah
- Dept. of Internal Medicine, Aga Khan University, Nairobi, Kenya
| | - Ji Zhu
- Dept. of Statistics, University of Michigan, LSA, Ann Arbor, Michigan, United States of America
| | - Matthew L Boulton
- Dept. of Epidemiology, School of Public Health, University of Michigan, Ann Arbor, Michigan, United States of America
| | - Timothy Hofer
- Center for Global Health Equity, Michigan Medicine, University of Michigan, Ann Arbor, Michigan, United States of America
| | - Akbar K Waljee
- Center for Global Health Equity, Michigan Medicine, University of Michigan, Ann Arbor, Michigan, United States of America
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Beste LA, Zhang X, Su GL, Van T, Ioannou GN, Oselio B, Tincopa M, Liu B, Singal AG, Zhu J, Waljee AK. Adapted time-varying covariates Cox model for predicting future cirrhosis development performs well in a large hepatitis C cohort. BMC Med Inform Decis Mak 2021; 21:347. [PMID: 34903225 PMCID: PMC8670121 DOI: 10.1186/s12911-021-01711-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2021] [Accepted: 11/30/2021] [Indexed: 11/16/2022] Open
Abstract
Background Patients with hepatitis C virus (HCV) frequently remain at risk for cirrhosis after sustained virologic response (SVR). Existing cirrhosis predictive models for HCV do not account for dynamic antiviral treatment status and are limited by fixed laboratory covariates and short follow up time. Advanced fibrosis assessment modalities, such as transient elastography, remain inaccessible in many settings. Improved cirrhosis predictive models are needed. Methods We developed a laboratory-based model to predict progression of liver disease after SVR. This prediction model used a time-varying covariates Cox model adapted to utilize longitudinal laboratory data and to account for antiretroviral treatment. Individuals were included if they had a history of detectable HCV RNA and at least 2 AST-to-platelet ratio index (APRI) scores available in the national Veterans Health Administration from 2000 to 2015, Observation time extended through January 2019. We excluded individuals with preexisting cirrhosis. Covariates included baseline patient characteristics and 16 time-varying laboratory predictors. SVR, defined as permanently undetectable HCV RNA after antiviral treatment, was modeled as a step function of time. Cirrhosis development was defined as two consecutive APRI scores > 2. We predicted cirrhosis development at 1-, 3-, and 5-years follow-up. Results In a national sample of HCV patients (n = 182,772) with a mean follow-up of 6.32 years, 42% (n = 76,854) achieved SVR before 2016 and 16.2% (n = 29,566) subsequently developed cirrhosis. The model demonstrated good discrimination for predicting cirrhosis across all combinations of laboratory data windows and cirrhosis prediction intervals. AUROCs ranged from 0.781 to 0.815, with moderate sensitivity 0.703–0.749 and specificity 0.723–0.767. Conclusion A novel adaptation of time-varying covariates Cox modeling technique using longitudinal laboratory values and dynamic antiviral treatment status accurately predicts cirrhosis development at 1-, 3-, and 5-years among patients with HCV, with and without SVR. It improves upon earlier cirrhosis predictive models and has many potential population-based applications, especially in settings without transient elastography available. Supplementary Information The online version contains supplementary material available at 10.1186/s12911-021-01711-7.
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Affiliation(s)
- Lauren A Beste
- General Medicine Service, Veterans Affairs Puget Sound Healthcare System, Seattle, WA, USA.,Department of Medicine, Veterans Affairs Puget Sound Healthcare System, Seattle, WA, USA
| | - Xuefei Zhang
- Department of Statistics and Biostatistics, University of Michigan, Ann Arbor, MI, USA.,Michigan Integrated Center for Health Analytics and Medical Prediction (MiCHAMP), Ann Arbor, MI, USA
| | - Grace L Su
- Gastroenterology Service, VA Ann Arbor Healthcare System, 2215 Fuller Road, Gastroenterology 111D, Ann Arbor, MI, 48105, USA.,Department of Internal Medicine, Michigan Medicine, Ann Arbor, MI, USA
| | - Tony Van
- Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI, USA
| | - George N Ioannou
- Gastroenterology Service, Veterans Affairs Puget Sound Healthcare System, Seattle, WA, USA.,Department of Medicine, University of Washington, Seattle, WA, USA
| | - Brandon Oselio
- Department of Statistics and Biostatistics, University of Michigan, Ann Arbor, MI, USA
| | - Monica Tincopa
- Department of Internal Medicine, Michigan Medicine, Ann Arbor, MI, USA
| | - Boang Liu
- Department of Statistics and Biostatistics, University of Michigan, Ann Arbor, MI, USA.,Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI, USA
| | - Amit G Singal
- Harold C. Simmons Comprehensive Cancer Center UT Southwestern Medical Center, Dallas, TX, USA.,Division of Digestive and Liver Diseases, Department of Internal Medicine, UT Southwestern Medical Center, Dallas, TX, USA.,Department of Internal Medicine, Parkland Health and Hospital System, Dallas, TX, USA
| | - Ji Zhu
- Department of Statistics and Biostatistics, University of Michigan, Ann Arbor, MI, USA.,Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, USA
| | - Akbar K Waljee
- Michigan Integrated Center for Health Analytics and Medical Prediction (MiCHAMP), Ann Arbor, MI, USA. .,Gastroenterology Service, VA Ann Arbor Healthcare System, 2215 Fuller Road, Gastroenterology 111D, Ann Arbor, MI, 48105, USA. .,Department of Internal Medicine, Michigan Medicine, Ann Arbor, MI, USA. .,Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI, USA. .,Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, USA.
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Berinstein JA, Sheehan J, Dias M, Berinstein EM, Steiner CA, Johnson LA, Regal RE, Allen JI, Cushing KC, Stidham RW, Bishu S, Kinnucan JA, Cohen-Mekelburg SA, Waljee AK, Higgins PD. Tofacitinib for Biologic-Experienced Hospitalized Patients With Acute Severe Ulcerative Colitis: A Retrospective Case-Control Study. Clin Gastroenterol Hepatol 2021; 19:2112-2120.e1. [PMID: 34048936 PMCID: PMC8760630 DOI: 10.1016/j.cgh.2021.05.038] [Citation(s) in RCA: 48] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2021] [Revised: 05/03/2021] [Accepted: 05/21/2021] [Indexed: 02/06/2023]
Abstract
BACKGROUND & AIMS Despite rescue therapy, more than 30% of patients with acute severe ulcerative colitis (ASUC) require colectomy. Tofacitinib is a rapidly acting Janus kinase inhibitor with proven efficacy in ulcerative colitis. Tofacitinib may provide additional means for preventing colectomy in patients with ASUC. METHODS A retrospective case-control study was performed evaluating the efficacy of tofacitinib induction in biologic-experienced patients admitted with ASUC requiring intravenous corticosteroids. Tofacitinib patients were matched 1:3 to controls according to gender and date of admission. Using Cox regression adjusted for disease severity, we estimated the 90-day risk of colectomy. Rates of complications and steroid dependence were examined as secondary outcomes. RESULTS Forty patients who received tofacitinib were matched 1:3 to controls (n = 113). Tofacitinib was protective against colectomy at 90 days compared with matched controls (hazard ratio [HR], 0.28, 95% confidence interval [CI], 0.10-0.81; P = .018). When stratifying according to treatment dose, 10 mg three times daily (HR, 0.11; 95% CI, 0.02-0.56; P = .008) was protective, whereas 10 mg twice daily was not significantly protective (HR, 0.66; 95% CI, 0.21-2.09; P = .5). Rate of complications and steroid dependence were similar between tofacitinib and controls. CONCLUSIONS Tofacitinib with concomitant intravenous corticosteroids may be an effective induction strategy in biologic-experienced patients hospitalized with ASUC. Prospective trials are needed to identify the safety, optimal dose, frequency, and duration of tofacitinib for ASUC.
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Affiliation(s)
- Jeffrey A. Berinstein
- Department of Internal Medicine, Division of Gastroenterology and Hepatology, Michigan Medicine, Ann Arbor, MI, USA.,Department of Internal Medicine, Michigan Medicine, Ann Arbor, MI, USA.,Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, USA
| | - Jessica Sheehan
- Department of Internal Medicine, Michigan Medicine, Ann Arbor, MI, USA
| | - Michael Dias
- Department of Internal Medicine, Michigan Medicine, Ann Arbor, MI, USA
| | | | - Calen A. Steiner
- Department of Internal Medicine, Division of Gastroenterology and Hepatology, Michigan Medicine, Ann Arbor, MI, USA.,Department of Internal Medicine, Michigan Medicine, Ann Arbor, MI, USA
| | - Laura A. Johnson
- Department of Internal Medicine, Division of Gastroenterology and Hepatology, Michigan Medicine, Ann Arbor, MI, USA
| | - Randolph E. Regal
- Department of Pharmacy Services, Michigan Medicine, Ann Arbor, MI, USA
| | - John I. Allen
- Department of Internal Medicine, Division of Gastroenterology and Hepatology, Michigan Medicine, Ann Arbor, MI, USA.,Department of Internal Medicine, Michigan Medicine, Ann Arbor, MI, USA.,Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, USA
| | - Kelly C. Cushing
- Department of Internal Medicine, Division of Gastroenterology and Hepatology, Michigan Medicine, Ann Arbor, MI, USA.,Department of Internal Medicine, Michigan Medicine, Ann Arbor, MI, USA
| | - Ryan W. Stidham
- Department of Internal Medicine, Division of Gastroenterology and Hepatology, Michigan Medicine, Ann Arbor, MI, USA.,Department of Internal Medicine, Michigan Medicine, Ann Arbor, MI, USA.,Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, USA
| | - Shrinivas Bishu
- Department of Internal Medicine, Division of Gastroenterology and Hepatology, Michigan Medicine, Ann Arbor, MI, USA.,Department of Internal Medicine, Michigan Medicine, Ann Arbor, MI, USA
| | - Jami A.R. Kinnucan
- Department of Internal Medicine, Division of Gastroenterology and Hepatology, Michigan Medicine, Ann Arbor, MI, USA.,Department of Internal Medicine, Michigan Medicine, Ann Arbor, MI, USA
| | - Shirley A. Cohen-Mekelburg
- Department of Internal Medicine, Division of Gastroenterology and Hepatology, Michigan Medicine, Ann Arbor, MI, USA.,Department of Internal Medicine, Michigan Medicine, Ann Arbor, MI, USA.,Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, USA,VA Center for Clinical Management Research, VA Ann Arbor Health Care System, Ann Arbor, MI, USA
| | - Akbar K. Waljee
- Department of Internal Medicine, Division of Gastroenterology and Hepatology, Michigan Medicine, Ann Arbor, MI, USA.,Department of Internal Medicine, Michigan Medicine, Ann Arbor, MI, USA.,Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, USA,VA Center for Clinical Management Research, VA Ann Arbor Health Care System, Ann Arbor, MI, USA.,Michigan Integrated Center for Health Analytics and Medical Prediction (MiCHAMP), Ann Arbor, MI, USA
| | - Peter D.R. Higgins
- Department of Internal Medicine, Division of Gastroenterology and Hepatology, Michigan Medicine, Ann Arbor, MI, USA.,Department of Internal Medicine, Michigan Medicine, Ann Arbor, MI, USA
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Read AJ, Waljee AK, Sussman JB, Singh H, Chen GY, Vijan S, Saini SD. Testing Practices, Interpretation, and Diagnostic Evaluation of Iron Deficiency Anemia by US Primary Care Physicians. JAMA Netw Open 2021; 4:e2127827. [PMID: 34596670 PMCID: PMC8486982 DOI: 10.1001/jamanetworkopen.2021.27827] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
IMPORTANCE Recognition of iron deficiency anemia (IDA) is important to initiate timely evaluation for gastrointestinal tract cancer. Retrospective studies have reported delays in diagnostic evaluation of IDA as a common factor associated with delayed diagnosis of colorectal cancer. OBJECTIVE To assess how US primary care physicians (PCPs) approach testing for anemia, interpret iron laboratory studies, and refer patients with IDA for gastrointestinal endoscopy. DESIGN, SETTING, AND PARTICIPANTS This survey study, conducted in August 2019, included members of the American College of Physicians Internal Medicine Insiders Panel, a nationally representative group of American College of Physicians membership, who self-identified as PCPs. Participants completed a vignette-based survey to assess practices related to screening for anemia, interpretation of laboratory-based iron studies, and appropriate diagnostic evaluation of IDA. MAIN OUTCOMES AND MEASURES Descriptive statistics based on survey responses were evaluated for frequency of anemia screening, correct interpretation of iron laboratory studies, and proportion of patients with new-onset IDA referred for gastrointestinal tract evaluation. RESULTS Of 631 PCPs who received an invitation to participate in the survey, 356 (56.4%) responded and 31 (4.9%) were excluded, for an adjusted eligible sample size of 600, yielding 325 completed surveys (response rate, 54.2%). Of the 325 participants who completed surveys, 180 (55.4%) were men; age of participants was not assessed. The mean (SD) duration of clinical experience was 19.8 (11.2) years (range, 1.0-45.0 years). A total of 250 participants (76.9%) screened at least some patients for anemia. Interpretation of iron studies was least accurate in a scenario of a borderline low ferritin level (40 ng/mL) with low transferrin saturation (2%); 86 participants (26.5%) incorrectly responded that this scenario did not indicate IDA, and 239 (73.5%) correctly identified this scenario as IDA. Of 312 participants, 170 (54.5%) recommended bidirectional endoscopy (upper endoscopy and colonoscopy) for new IDA for women aged 65 years; of 305 respondents, 168 (55.1%) recommended bidirectional endoscopy for men aged 65 years. CONCLUSIONS AND RELEVANCE In this survey study, US PCPs' self-reported testing practices for anemia suggest overuse of screening laboratory tests, misinterpretation of iron studies, and underuse of bidirectional endoscopy for evaluation of new-onset IDA. Both misinterpretation of iron studies and underuse of bidirectional endoscopy can lead to delayed diagnosis of gastrointestinal tract cancers and warrant additional interventions.
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Affiliation(s)
- Andrew J. Read
- Department of Internal Medicine, University of Michigan, Ann Arbor
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor
| | - Akbar K. Waljee
- Department of Internal Medicine, University of Michigan, Ann Arbor
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor
- Veterans Affairs Health Services Research and Development, Center for Clinical Management Research, Ann Arbor, Michigan
| | - Jeremy B. Sussman
- Department of Internal Medicine, University of Michigan, Ann Arbor
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor
- Veterans Affairs Health Services Research and Development, Center for Clinical Management Research, Ann Arbor, Michigan
| | - Hardeep Singh
- Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey Veterans Affairs Medical Center and Baylor College of Medicine, Houston, Texas
| | - Grace Y. Chen
- Department of Internal Medicine, University of Michigan, Ann Arbor
| | - Sandeep Vijan
- Department of Internal Medicine, University of Michigan, Ann Arbor
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor
- Veterans Affairs Health Services Research and Development, Center for Clinical Management Research, Ann Arbor, Michigan
| | - Sameer D. Saini
- Department of Internal Medicine, University of Michigan, Ann Arbor
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor
- Veterans Affairs Health Services Research and Development, Center for Clinical Management Research, Ann Arbor, Michigan
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Piper MS, Zikmund-Fisher BJ, Maratt JK, Kurlander J, Metko V, Waljee AK, Saini SD. Patients' Willingness to Share Limited Endoscopic Resources: A Brief Report on the Results of a Large Regional Survey. MDM Policy Pract 2021; 6:23814683211045648. [PMID: 34616912 PMCID: PMC8488065 DOI: 10.1177/23814683211045648] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2017] [Accepted: 08/05/2021] [Indexed: 12/25/2022] Open
Abstract
Background. In some health care systems, patients face long wait times for screening colonoscopy. We sought to assess whether patients at low risk for colorectal cancer (CRC) would be willing to delay their own colonoscopy so higher-risk peers could undergo colonoscopy sooner. Methods. We surveyed 1054 Veterans regarding their attitudes toward repeat colonoscopy and risk-based prioritization. We used multivariable regression to identify patient factors associated with willingness to delay screening for a higher-risk peer. Results. Despite a physician recommendation to stop screening, 29% of respondents reported being "not at all likely" to stop. However, 94% reported that they would be willing to delay their own colonoscopy for a higher-risk peer. Greater trust in physician and greater health literacy were positively associated with willingness to wait, while greater perceived threat of CRC and Black or Latino race/ethnicity were negatively associated with willingness to wait. Conclusion. Despite high enthusiasm for repeat screening, patients were willing to delay their own colonoscopy for higher-risk peers. Appealing to altruism could be effective when utilizing scarce resources.
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Affiliation(s)
- Marc S. Piper
- Marc S. Piper, 30055 Northwestern Highway,
Suite 250, Farmington Hills, MI 48334, USA; Telephone: (248) 882-8639
()
| | - Brian J. Zikmund-Fisher
- Department of Health Behavior and Health
Education, University of Michigan School of Public Health, Ann Arbor,
Michigan,Department of Internal Medicine, University of
Michigan Medical School, Ann Arbor, Michigan
| | - Jennifer K. Maratt
- Division of Gastroenterology, Department of
Internal Medicine, University of Michigan, Ann Arbor, Michigan,Division of Gastroenterology, Department of
Internal Medicine, Indiana University School of Medicine, Indianapolis,
Indiana,Richard L. Roudebush VA Medical Center,
Indianapolis, Indiana,Regenstrief Institute, Inc, Indianapolis,
Indiana
| | - Jacob Kurlander
- Division of Gastroenterology, Department of
Internal Medicine, University of Michigan, Ann Arbor, Michigan,VA HSR&D Center for Clinical Management
Research, VA Ann Arbor Healthcare System, Ann Arbor, Michigan
| | - Valbona Metko
- Division of Gastroenterology, Department of
Internal Medicine, University of Michigan, Ann Arbor, Michigan
| | - Akbar K. Waljee
- Division of Gastroenterology, Department of
Internal Medicine, University of Michigan, Ann Arbor, Michigan,VA HSR&D Center for Clinical Management
Research, VA Ann Arbor Healthcare System, Ann Arbor, Michigan
| | - Sameer D. Saini
- Division of Gastroenterology, Department of
Internal Medicine, University of Michigan, Ann Arbor, Michigan,VA HSR&D Center for Clinical Management
Research, VA Ann Arbor Healthcare System, Ann Arbor, Michigan
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49
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Gan RW, Sun D, Tatro AR, Cohen-Mekelburg S, Wiitala WL, Zhu J, Waljee AK. Replicating prediction algorithms for hospitalization and corticosteroid use in patients with inflammatory bowel disease. PLoS One 2021; 16:e0257520. [PMID: 34543353 PMCID: PMC8452029 DOI: 10.1371/journal.pone.0257520] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2021] [Accepted: 09/04/2021] [Indexed: 12/14/2022] Open
Abstract
Introduction Previous work had shown that machine learning models can predict inflammatory bowel disease (IBD)-related hospitalizations and outpatient corticosteroid use based on patient demographic and laboratory data in a cohort of United States Veterans. This study aimed to replicate this modeling framework in a nationally representative cohort. Methods A retrospective cohort design using Optum Electronic Health Records (EHR) were used to identify IBD patients, with at least 12 months of follow-up between 2007 and 2018. IBD flare was defined as an inpatient/emergency visit with a diagnosis of IBD or an outpatient corticosteroid prescription for IBD. Predictors included demographic and laboratory data. Logistic regression and random forest (RF) models were used to predict IBD flare within 6 months of each visit. A 70% training and 30% validation approach was used. Results A total of 95,878 patients across 780,559 visits were identified. Of these, 22,245 (23.2%) patients had at least one IBD flare. Patients were predominantly White (87.7%) and female (57.1%), with a mean age of 48.0 years. The logistic regression model had an area under the receiver operating curve (AuROC) of 0.66 (95% CI: 0.65−0.66), sensitivity of 0.69 (95% CI: 0.68−0.70), and specificity of 0.74 (95% CI: 0.73−0.74) in the validation cohort. The RF model had an AuROC of 0.80 (95% CI: 0.80−0.81), sensitivity of 0.74 (95% CI: 0.73−0.74), and specificity of 0.72 (95% CI: 0.72−0.72) in the validation cohort. Important predictors of IBD flare in the RF model were the number of previous flares, age, potassium, and white blood cell count. Conclusion The machine learning modeling framework was replicated and results showed a similar predictive accuracy in a nationally representative cohort of IBD patients. This modeling framework could be embedded in routine practice as a tool to distinguish high-risk patients for disease activity.
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Affiliation(s)
- Ryan W. Gan
- Genentech, Inc., South San Francisco, California, United States of America
| | - Diana Sun
- Genentech, Inc., South San Francisco, California, United States of America
| | | | - Shirley Cohen-Mekelburg
- University of Michigan Health System, Ann Arbor, Michigan, United States of America
- Veterans Affairs Health Care System, Center for Clinical Management Research, Ann Arbor, Michigan, United States of America
| | - Wyndy L. Wiitala
- Veterans Affairs Health Care System, Center for Clinical Management Research, Ann Arbor, Michigan, United States of America
| | - Ji Zhu
- Department of Statistics, University of Michigan, Ann Arbor, Michigan, United States of America
| | - Akbar K. Waljee
- University of Michigan Health System, Ann Arbor, Michigan, United States of America
- Veterans Affairs Health Care System, Center for Clinical Management Research, Ann Arbor, Michigan, United States of America
- * E-mail:
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50
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Read AJ, Waljee AK, Saini SD. A National Survey of Adoption of the 2018 American Cancer Society Colorectal Cancer Screening Guideline in Primary Care. Clin Gastroenterol Hepatol 2021; 19:1973-1975.e1. [PMID: 32871285 PMCID: PMC9443500 DOI: 10.1016/j.cgh.2020.08.060] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2020] [Revised: 08/24/2020] [Accepted: 08/26/2020] [Indexed: 02/07/2023]
Abstract
Recent data have shown increasing incidence of colorectal cancer (CRC) among those younger than 50 years of age.1,2 In response, the American Cancer Society (ACS) introduced new guidelines in May 2018 that recommend initiation of CRC screening in average-risk adults at age 45, which is 5 years earlier than existing recommendations from the US Preventive Services Task Force and US Multi-Society Task Force on Colorectal Cancer.3-5 Most screening colonoscopies are ordered directly by primary care providers (PCPs) via "direct" or "open.
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Affiliation(s)
- Andrew J. Read
- Division of Gastroenterology, University of Michigan, Ann Arbor, MI,Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI
| | - Akbar K. Waljee
- Division of Gastroenterology, University of Michigan, Ann Arbor, MI,Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI,VA HSR&D Center for Clinical Management Research, Ann Arbor, MI
| | - Sameer D. Saini
- Division of Gastroenterology, University of Michigan, Ann Arbor, MI,Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI,VA HSR&D Center for Clinical Management Research, Ann Arbor, MI
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