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Erickson SJ, Yabes JG, Han Z, Roumelioti ME, Rollman BL, Weisbord SD, Steel JL, Unruh ML, Jhamb M. Associations Between Social Support and Patient-Reported Outcomes in Hemodialysis Patients: Results from the TACcare Study. Kidney360 2024:02200512-990000000-00391. [PMID: 38704664 DOI: 10.34067/kid.0000000000000456] [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] [Received: 12/05/2023] [Accepted: 04/22/2024] [Indexed: 05/06/2024]
Abstract
BACKGROUND End Stage Kidney Disease (ESKD) patients experience high symptom burden which has been associated with a negative impact on their interpersonal relationships. However, there is limited research exploring associations of social support and patient-reported outcomes among hemodialysis (HD) patients. METHODS The current study is a secondary, cross-sectional analyses of the sociodemographic and clinical correlates of perceived social support (Multidimensional Scale of Perceived Social Support; MSPSS) at baseline. The study examined the extent to which perceived social support is associated with pain, depression, fatigue, anxiety, sleep, and HRQoL (SF-12 Mental Component Score; MCS) and Physical Component Score; PCS)). RESULTS Of the 160 randomized patients: mean (SD) age was 58 ±14 years; years on dialysis was 4.1 + 4.2; 45% were female; 29% Black, 13% American Indian, 18% Hispanic; 88% had at least high school education; and 27% were married. Mean baseline levels of perceived social support were comparable to other chronically ill populations. At least a high school education (p = 0.04) and being married (p = 0.05) were associated with higher total MSPSS scores. Higher MSPSS scores were correlated with lower levels of fatigue (r = 0.21, p =0.008; higher fatigue scores signify lower fatigue), pain (r = -0.17, p = 0.03), depressive symptoms (r = -0.26, p < 0.001), anxiety (r = -0.23, p = 0.004), better sleep quality (r = -0.32, p < 0.001) and SF-12 MCS (r = 0.26, p <0.001). Moderation analyses revealed male sex and non-Hispanic ethnicity resulted in stronger positive associations of perceived social support with SF-12 MCS. CONCLUSIONS The level of perceived social support observed among thrice weekly HD patients in TACcare was similar to those observed in other chronic conditions. Because of the associations between perceived social support and patient-reported outcomes, particularly psychosocial and behavioral health outcomes, targeting social support appears to be warranted among HD patients.
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Affiliation(s)
- Sarah J Erickson
- Department of Psychology, University of New Mexico, Albuquerque, NM, USA
| | - Jonathan G Yabes
- Center for Research on Heath Care Data Center, Division of General Internal Medicine, Department of Medicine and Biostatistics, University of Pittsburgh, Pittsburgh, PA, USA
| | - Zhuoheng Han
- Renal-Electrolyte Division, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Maria-Eleni Roumelioti
- Division of Nephrology, Department of Internal Medicine, University of New Mexico School of Medicine Albuquerque, NM, USA
| | - Bruce L Rollman
- Center for Behavioral Health, Media, and Technology, Division of General Internal Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Steven D Weisbord
- Renal Section and Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA, USA
| | - Jennifer L Steel
- Department of Surgery, Psychiatry and Psychology, University of Pittsburgh, Pittsburgh, PA, USA
| | - Mark L Unruh
- Division of Nephrology, Department of Internal Medicine, University of New Mexico School of Medicine Albuquerque, NM, USA
| | - Manisha Jhamb
- Renal-Electrolyte Division, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
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Jhamb M, Weltman MR, Devaraj SM, Lavenburg LMU, Han Z, Alghwiri AA, Fischer GS, Rollman BL, Nolin TD, Yabes JG. Electronic Health Record Population Health Management for Chronic Kidney Disease Care: A Cluster Randomized Clinical Trial. JAMA Intern Med 2024:2817606. [PMID: 38619824 PMCID: PMC11019443 DOI: 10.1001/jamainternmed.2024.0708] [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: 10/05/2023] [Accepted: 02/12/2024] [Indexed: 04/16/2024]
Abstract
Importance Large gaps in clinical care in patients with chronic kidney disease (CKD) lead to poor outcomes. Objective To compare the effectiveness of an electronic health record-based population health management intervention vs usual care for reducing CKD progression and improving evidence-based care in high-risk CKD. Design, Setting, and Participants The Kidney Coordinated Health Management Partnership (Kidney CHAMP) was a pragmatic cluster randomized clinical trial conducted between May 2019 and July 2022 in 101 primary care practices in Western Pennsylvania. It included patients aged 18 to 85 years with an estimated glomerular filtration rate (eGFR) of less than 60 mL/min/1.73m2 with high risk of CKD progression and no outpatient nephrology encounter within the previous 12 months. Interventions Multifaceted intervention for CKD comanagement with primary care clinicians included a nephrology electronic consultation, pharmacist-led medication management, and CKD education for patients. The usual care group received CKD care from primary care clinicians as usual. Main Outcomes and Measures The primary outcome was time to 40% or greater reduction in eGFR or end-stage kidney disease. Results Among 1596 patients (754 intervention [47.2%]; 842 control [52.8%]) with a mean (SD) age of 74 (9) years, 928 (58%) were female, 127 (8%) were Black, 9 (0.6%) were Hispanic, and the mean (SD) estimated glomerular filtration rate was 36.8 (7.9) mL/min/1.73m2. Over a median follow-up of 17.0 months, there was no significant difference in rate of primary outcome between the 2 arms (adjusted hazard ratio, 0.96; 95% CI, 0.67-1.38; P = .82). Angiotensin-converting enzyme inhibitor/angiotensin receptor blocker exposure was more frequent in intervention arm compared with the control group (rate ratio, 1.21; 95% CI, 1.02-1.43). There was no difference in the secondary outcomes of hypertension control and exposure to unsafe medications or adverse events between the arms. Several COVID-19-related issues contributed to null findings in the study. Conclusion and Relevance In this study, among patients with moderate-risk to high-risk CKD, a multifaceted electronic health record-based population health management intervention resulted in more exposure days to angiotensin-converting enzyme inhibitors/angiotensin receptor blockers but did not reduce risk of CKD progression or hypertension control vs usual care. Trial Registration ClinicalTrials.gov Identifier: NCT03832595.
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Affiliation(s)
- Manisha Jhamb
- Renal-Electrolyte Division, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Melanie R. Weltman
- Renal-Electrolyte Division, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
- Department of Pharmacy and Therapeutics, University of Pittsburgh School of Pharmacy, Pittsburgh, Pennsylvania
| | - Susan M. Devaraj
- Renal-Electrolyte Division, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Linda-Marie Ustaris Lavenburg
- Renal-Electrolyte Division, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Zhuoheng Han
- Renal-Electrolyte Division, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Alaa A. Alghwiri
- Renal-Electrolyte Division, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Gary S. Fischer
- Division of General Internal Medicine, Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Bruce L. Rollman
- Division of General Internal Medicine, Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
- Center for Behavioral Health, Media, and Technology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Thomas D. Nolin
- Renal-Electrolyte Division, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
- Department of Pharmacy and Therapeutics, University of Pittsburgh School of Pharmacy, Pittsburgh, Pennsylvania
| | - Jonathan G. Yabes
- Division of General Internal Medicine, Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
- Center for Research on Heath Care, Division of General Internal Medicine, Department of Medicine and Biostatistics, University of Pittsburgh, Pittsburgh, Pennsylvania
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Steel JL, George CJ, Terhorst L, Yabes JG, Reyes V, Zandberg DP, Nilsen M, Kiefer G, Johnson J, Marsh C, Bierenbaum J, Tageja N, Krauze M, VanderWeele R, Goel G, Ramineni G, Antoni M, Vodovotz Y, Walker J, Tohme S, Billiar T, Geller DA. Patient, family caregiver, and economic outcomes of an integrated screening and novel stepped collaborative care intervention in the oncology setting in the USA (CARES): a randomised, parallel, phase 3 trial. Lancet 2024; 403:1351-1361. [PMID: 38490230 DOI: 10.1016/s0140-6736(24)00015-1] [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] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2023] [Revised: 12/06/2023] [Accepted: 01/03/2024] [Indexed: 03/17/2024]
Abstract
BACKGROUND The current standard of care of screening and referring patients for treatment for symptoms, such as depression, pain, and fatigue, is not effective. This trial aimed to test the efficacy of an integrated screening and novel stepped collaborative care intervention versus standard of care for patients with cancer and at least one of the following symptoms: depression, pain, or fatigue. METHODS This randomised, parallel, phase 3 trial was conducted in 29 oncology outpatient clinics associated with the UPMC Hillman Cancer Center in the USA. Patients (aged ≥21 years) with any cancer type and clinical levels of depression, pain, or fatigue (or all of these) were eligible. Eligible family caregivers were aged 21 years or older and providing care to a patient diagnosed with cancer who consented for this study. Patients were randomly assigned (1:1) to stepped collaborative care or standard of care using a central, permuted block design (sizes of 2, 4, and 6) stratified by sex and prognostic status. The biostatistician, oncologists, and outcome assessors were masked to treatment assignment. Stepped collaborative care was once-weekly cognitive behavioural therapy for 50-60 min from a care coordinator via telemedicine (eg, telephone or videoconferencing). Pharmacotherapy for symptoms might be initiated or changed if recommended by the treatment team or preferred by the patient. Standard of care was screening and referral to a health-care provider for treatment of symptoms. The primary outcome was health-related quality of life in patients at 6 months. Maintenance of the treatment benefits was assessed at 12 months. Participants included in the primary analysis were per intention to treat, which included patients missing one or both follow-up assessments. This trial was registered with ClinicalTrials.gov (NCT02939755). FINDINGS Between Dec 5, 2016, and April 8, 2021, 459 patients and 190 family caregivers were enrolled. 222 patients were assigned to standard of care and 237 to stepped collaborative care. Of 459 patients, 201 (44%) were male and 258 (56%) were female. Patients in the stepped collaborative care group had a greater 0-6-month improvement in health-related quality of life than patients in the standard-of-care group (p=0·013, effect size 0·09). Health-related quality of life was maintained for the stepped collaborative care group (p=0·74, effect size 0·01). Patients in the stepped collaborative care group had greater 0-6-month improvements than the standard-of-care group in emotional (p=0·012), functional (p=0·042), and physical (p=0·033) wellbeing. No adverse events were reported by patients in either group and deaths were considered unrelated to the study. INTERPRETATION An integrated screening and novel stepped collaborative care intervention, compared with the current standard of care, is recommended to improve health-related quality of life. The findings of this study will advance the implementation of guideline concordant care (screening and treatment) and has the potential to shift the practice of screening and treatment paradigm nationwide, improving outcomes for patients diagnosed with cancer. FUNDING US National Cancer Institute.
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Affiliation(s)
- Jennifer L Steel
- Department of Surgery, School of Medicine, University of Pittsburgh, Pittsburgh, PA, USA; Department of Psychiatry, School of Medicine, University of Pittsburgh, Pittsburgh, PA, USA; Department of Psychology, Dietrich School of Arts and Sciences, University of Pittsburgh, Pittsburgh, PA, USA.
| | - Charles J George
- School of Health and Rehabilitation Sciences, University of Pittsburgh, Pittsburgh, PA, USA
| | - Lauren Terhorst
- School of Health and Rehabilitation Sciences, University of Pittsburgh, Pittsburgh, PA, USA
| | - Jonathan G Yabes
- Department of Medicine, School of Medicine, University of Pittsburgh, Pittsburgh, PA, USA; Department of Biostatistics, School of Public Health, University of Pittsburgh, Pittsburgh, PA, USA; Clinical and Translational Science Institute, University of Pittsburgh, Pittsburgh, PA, USA
| | | | - Dan P Zandberg
- Department of Medicine, School of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Marci Nilsen
- Department of Acute and Tertiary Care, School of Nursing, University of Pittsburgh, Pittsburgh, PA, USA
| | | | - Jonas Johnson
- Department of Otolaryngology, School of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | | | | | | | | | | | - Gaurav Goel
- UPMC Hillman Cancer Center, Pittsburgh, PA, USA
| | | | - Michael Antoni
- Department of Psychology, Sylvester Cancer Center, University of Miami, FL, USA
| | - Yoram Vodovotz
- Department of Surgery, School of Medicine, University of Pittsburgh, Pittsburgh, PA, USA; Department of Immunology, School of Medicine, University of Pittsburgh, Pittsburgh, PA, USA; Department of Computational and Systems Biology, School of Medicine, University of Pittsburgh, Pittsburgh, PA, USA; Department of Bioengineering, School of Engineering, University of Pittsburgh, Pittsburgh, PA, USA; Department of Communication Science and Disorders, University of Pittsburgh, Pittsburgh, PA, USA; Clinical and Translational Science Institute, University of Pittsburgh, Pittsburgh, PA, USA
| | - Jon Walker
- School of Information Sciences, University of Pittsburgh, Pittsburgh, PA, USA
| | - Samer Tohme
- Department of Surgery, School of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Timothy Billiar
- Department of Surgery, School of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - David A Geller
- Department of Surgery, School of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
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Staniorski CJ, Yu M, Sharbaugh D, Stencel MG, Myrga JM, Davies BJ, Yabes JG, Jacobs B. Predictors of persistent opioid use in bladder cancer patients undergoing radical cystectomy: A SEER-Medicare analysis. Urol Oncol 2024:S1078-1439(24)00362-4. [PMID: 38565428 DOI: 10.1016/j.urolonc.2024.03.010] [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] [Subscribe] [Scholar Register] [Received: 11/04/2023] [Revised: 12/19/2023] [Accepted: 03/10/2024] [Indexed: 04/04/2024]
Abstract
PURPOSE To evaluate patient and provider characteristics that predict persistent opioid use following radical cystectomy for bladder cancer including non-opioid naïve patients. METHODS Patients undergoing cystectomy between July 2007 and December 2015 were identified using the SEER-Medicare database. Opioid exposure was identified before and after cystectomy using Medicare Part D data. Multivariable analyses were used to identify predictors of the primary outcomes: persistent opioid use (prescription 3-6 months after surgery) and postoperative opioid prescriptions (within 30 days of surgery). Secondary outcomes included physician prescribing practices and rates of persistent opioid use in their patient cohorts. RESULTS A total of 1,774 patients were included; 29% had prior opioid exposure. Compared to opioid-naïve patients, non-opioid naïve patients were more frequently younger, Black, and living in less educated communities. The percentage of persistent postoperative use was 10% overall and 24% in non-opioid naïve patients. Adjusting for patient factors, opioid naïve individuals were less likely to develop persistent use (OR 0.23) while a 50-unit increase in oral morphine equivalent per day prescribed following surgery nearly doubled the likelihood of persistent use (OR 1.98). Practice factors such as hospital size, teaching affiliation, and hospital ownership failed to predict persistent use. 29% of patients filled an opioid prescription postoperatively. Opioid naïve patients (OR 0.13) and those cared for at government hospitals (OR 0.59) were less likely to fill an opioid script along with those residing in the Northeast. Variability between physicians was seen in prescribing practices and rates of persistent use. CONCLUSIONS Non-opioid naïve patients have higher rates of post-operative opioid prescription than opioid-naïve patients. Physician prescribing practices play a role in persistent use, as initial prescription amount predicts persistent use even in non-opioid naïve patients. Significant physician variation in both prescribing practices and rates of persistent use suggest a role for standardizing practices.
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Affiliation(s)
- Christopher J Staniorski
- Division of Health Services Research, Department of Urology, University of Pittsburgh Medical Center, Kaufmann Medical Building 3471 Fifth Ave, Suite 700, Pittsburgh, PA 15213.
| | - Michelle Yu
- Division of Health Services Research, Department of Urology, University of Pittsburgh Medical Center, Kaufmann Medical Building 3471 Fifth Ave, Suite 700, Pittsburgh, PA 15213
| | - Danielle Sharbaugh
- Division of Health Services Research, Department of Urology, University of Pittsburgh Medical Center, Kaufmann Medical Building 3471 Fifth Ave, Suite 700, Pittsburgh, PA 15213
| | - Michael G Stencel
- Department of Urology, Charleston Area Medical Center, 3100 MacCorkle Ave Se Suite 602, Charleston, WV 25304
| | - John M Myrga
- Division of Health Services Research, Department of Urology, University of Pittsburgh Medical Center, Kaufmann Medical Building 3471 Fifth Ave, Suite 700, Pittsburgh, PA 15213
| | - Benjamin J Davies
- Division of Health Services Research, Department of Urology, University of Pittsburgh Medical Center, Kaufmann Medical Building 3471 Fifth Ave, Suite 700, Pittsburgh, PA 15213
| | - Jonathan G Yabes
- Division of Health Services Research, Department of Urology, University of Pittsburgh Medical Center, Kaufmann Medical Building 3471 Fifth Ave, Suite 700, Pittsburgh, PA 15213; Division of Internal Medicine, Department of Medicine, University of Pittsburgh Medical Center, 1218 Scaife Hall, 3550 Terrace Street, Pittsburgh, PA 15261
| | - Bruce Jacobs
- Division of Health Services Research, Department of Urology, University of Pittsburgh Medical Center, Kaufmann Medical Building 3471 Fifth Ave, Suite 700, Pittsburgh, PA 15213
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Wittman SR, Hoberman A, Mehrotra A, Sabik LM, Yabes JG, Ray KN. Antibiotic Receipt for Pediatric Telemedicine Visits With Primary Care vs Direct-to-Consumer Vendors. JAMA Netw Open 2024; 7:e242359. [PMID: 38483387 PMCID: PMC10940962 DOI: 10.1001/jamanetworkopen.2024.2359] [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] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2023] [Accepted: 01/23/2024] [Indexed: 03/17/2024] Open
Abstract
Importance Prior research found that pediatric direct-to-consumer (DTC) telemedicine visits are associated with more antibiotic prescribing than in-person primary care visits. It is unclear whether this difference is associated with modality of care (telemedicine vs in-person) or with the context of telemedicine care (primary care vs not primary care). Objective To compare antibiotic management during telemedicine visits with primary care practitioners (PCPs) vs commercial direct-to-consumer (DTC) telemedicine companies for pediatric acute respiratory tract infections (ARTIs). Design, Setting, and Participants This retrospective, cross-sectional study of visits for ARTIs by commercially insured children 17 years of age or younger analyzed deidentified medical and pharmacy claims in OptumLabs Data Warehouse data, a national sample of commercial enrollees, between January 1 and December 31, 2022. Exposure Setting of telemedicine visit as PCP vs DTC. Main Outcomes and Measures The primary outcome was percentage of visits with antibiotic receipt. Secondary outcomes were the percentages of visits with diagnoses for which prescription of an antibiotic was potentially appropriate, guideline-concordant antibiotic management, and follow-up ARTI visits within the ensuing 1 to 2 days and 3 to 14 days. The ARTI telemedicine visits with PCP vs DTC telemedicine companies were matched on child demographic characteristics. Generalized estimated equation log-binomial regression models were used to compute marginal outcomes. Results In total, data from 27 686 children (mean [SD] age, 8.9 [5.0] years; 13 893 [50.2%] male) were included in this study. There were 14 202 PCP telemedicine index visits matched to 14 627 DTC telemedicine index visits. The percentage of visits involving receipt of an antibiotic was lower for PCP (28.9% [95% CI, 28.1%-29.7%]) than for DTC (37.2% [95% CI, 36.0%-38.5%]) telemedicine visits. Additionally, fewer PCP telemedicine visits involved receipt of a diagnosis in which the use of antibiotics may be appropriate (19.0% [95% CI, 18.4%-19.7%] vs 28.4% [95% CI, 27.3%-29.6%]), but no differences were observed in receipt of nonguideline-concordant antibiotic management based on a given diagnosis between PCP (20.2% [95% CI, 19.5%-20.9%]) and DTC (20.1% [95% CI, 19.1%-21.0%]) telemedicine visits. Fewer PCP telemedicine visits involved a follow-up visit within the ensuing 1 to 2 days (5.0% [95% CI, 4.7%-5.4%] vs 8.0% [95% CI, 7.3%-8.7%]) and 3 to 14 days (8.2% [95% CI, 7.8%-8.7%] vs 9.6% [95% CI, 8.8%-10.3%]). Conclusions and Relevance Compared with virtual-only DTC telemedicine companies, telemedicine integrated within primary care was associated with lower rates of antibiotic receipt and follow-up care. Supporting use of telemedicine integrated within pediatric primary care may be one strategy to reduce antibiotic receipt through telemedicine visits.
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Affiliation(s)
- Samuel R. Wittman
- Department of Pediatrics, University of Pittsburgh School of Medicine, UPMC Children’s Hospital of Pittsburgh, Pittsburgh, Pennsylvania
| | - Alejandro Hoberman
- Department of Pediatrics, University of Pittsburgh School of Medicine, UPMC Children’s Hospital of Pittsburgh, Pittsburgh, Pennsylvania
| | - Ateev Mehrotra
- Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts
| | - Lindsay M. Sabik
- Department of Health Policy and Management, University of Pittsburgh School of Public Health, Pittsburgh, Pennsylvania
| | - Jonathan G. Yabes
- Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Kristin N. Ray
- Department of Pediatrics, University of Pittsburgh School of Medicine, UPMC Children’s Hospital of Pittsburgh, Pittsburgh, Pennsylvania
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Sharbaugh AJ, Sharbaugh DR, Lin JY, Pekala KR, Yabes JG, Yu M, Grajales V, Shah A, Worku H, Hay JM, Zhu TS, Akomolede O, Armann KM, Hudson CN, Davies BJ, Jacobs BL. Using a Multi-pronged Behavioral Intervention to Standardize Antibiotic Prophylaxis at the Time of Foley Catheter Removal After Radical Prostatectomy. Urology 2024; 184:157-161. [PMID: 37774852 DOI: 10.1016/j.urology.2023.09.017] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2023] [Revised: 08/31/2023] [Accepted: 09/19/2023] [Indexed: 10/01/2023]
Abstract
OBJECTIVE To identify antibiotic prescribing patterns at the time of foley catheter removal after radical prostatectomy and implement a multi-pronged behavioral intervention to standardize antibiotic use. METHODS This was a single-institution study examining the prescribing of antibiotics at the time of foley catheter removal after radical prostatectomy. Pre-intervention data were collected retrospectively to establish baselines for antibiotic prescribing, patient characteristics, and urinary tract infection rates. A single dose of an oral antibiotic taken at the time of foley catheter removal was recommended as the standard antibiotic protocol. A multi-pronged behavioral intervention was used to encourage compliance with our protocol. Adherence to the protocol, quantity of antibiotics prescribed, and rate of urinary tract infection were recorded prospectively. Durability of the intervention was evaluated during a post-intervention phase. RESULTS A total of 416 patients and 6 surgeons were included in the study. Accordance with the standardized antibiotic protocol was 59% in the pre-intervention phase and 91% in the intervention phase (P = .03). No patients in the intervention or post-intervention phase were prescribed more than one dose of an antibiotic. The rate of urinary tract infection did not differ across the study phases. CONCLUSION Implementation of a multi-pronged behavioral intervention resulted in a high rate of surgeon compliance with a standardized antibiotic protocol. This led to a significant reduction in antibiotic use with no change in the rate of urinary tract infection after foley catheter removal after radical prostatectomy.
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Affiliation(s)
- Adam J Sharbaugh
- Department of Urology, University of Pittsburgh, Pittsburgh, PA.
| | - Danielle R Sharbaugh
- Department of Urology, University of Pittsburgh, Pittsburgh, PA; Urology Health Services Research Division, University of Pittsburgh, Pittsburgh, PA
| | - Jonathan Y Lin
- Department of Urology, University of Pittsburgh, Pittsburgh, PA; Urology Health Services Research Division, University of Pittsburgh, Pittsburgh, PA
| | - Kelly R Pekala
- Department of Urology, University of Pittsburgh, Pittsburgh, PA
| | - Jonathan G Yabes
- Center for Research on Health Care, University of Pittsburgh, Pittsburgh, PA; Department of Medicine, University of Pittsburgh, Pittsburgh, PA
| | - Michelle Yu
- Department of Urology, University of Pittsburgh, Pittsburgh, PA
| | | | - Anup Shah
- Department of Urology, University of Pittsburgh, Pittsburgh, PA
| | - Hermoon Worku
- University of Pittsburgh School of Medicine, University of Pittsburgh, Pittsburgh, PA
| | - Jordan M Hay
- University of Pittsburgh School of Medicine, University of Pittsburgh, Pittsburgh, PA
| | - Toby S Zhu
- University of Pittsburgh School of Medicine, University of Pittsburgh, Pittsburgh, PA
| | - Olutiwa Akomolede
- University of Pittsburgh School of Medicine, University of Pittsburgh, Pittsburgh, PA
| | - Kody M Armann
- University of Pittsburgh School of Medicine, University of Pittsburgh, Pittsburgh, PA
| | - Chandler N Hudson
- University of Pittsburgh School of Medicine, University of Pittsburgh, Pittsburgh, PA
| | - Benjamin J Davies
- Department of Urology, University of Pittsburgh, Pittsburgh, PA; Urology Health Services Research Division, University of Pittsburgh, Pittsburgh, PA
| | - Bruce L Jacobs
- Department of Urology, University of Pittsburgh, Pittsburgh, PA; Urology Health Services Research Division, University of Pittsburgh, Pittsburgh, PA
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Gul ZG, Sharbaugh DR, Ellimoottil C, Rak KJ, Yabes JG, Davies BJ, Jacobs BL. Telemedicine in urologic oncology care: Will telemedicine exacerbate disparities? Urol Oncol 2024; 42:28.e1-28.e7. [PMID: 38220521 DOI: 10.1016/j.urolonc.2023.10.002] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2023] [Revised: 09/15/2023] [Accepted: 10/16/2023] [Indexed: 01/16/2024]
Abstract
INTRODUCTION Disparities in prostate, bladder, and kidney cancer outcomes are associated with access to care. Telemedicine can improve access but may be underutilized by certain patient populations. Our objective was to determine if the patient populations who suffer worse oncologic outcomes are the same as those who are less likely to use telemedicine. METHODS Using an institutional database, we identified all prostate, bladder and kidney cancer encounters from March 14, 2020 to October 31, 2021 (n = 15,623; n = 4, 14; n = 3,830). Telemedicine was used in 13%, 8%, and 12% of these encounters, respectively. We performed random effects modeling analysis to examine patient and provider characteristics associated with telemedicine use. Adjusted odds ratios (OR) and 95% confidence intervals (CI) were reported as measures of association. RESULTS Among prostate, bladder, and kidney cancer patients, Black patients had lower odds of a telemedicine encounter (OR 0.51, 95% CI 0.37-0.69; OR 0.22, 95% CI 0.07-0.70; OR 0.46, 95% CI 0.24-0.86), and patients residing in small and isolated small rural towns areas had higher odds of a telemedicine encounter (OR 1.44, 95% CI 1.09-1.91; OR 2.12, 95% CI 1.14-3.94; OR 1.89, 95% CI 1.12-3.19). Compared to providers in practice ≤5 years, providers in practice for 6 to 15 years had significantly higher odds of a telemedicine encounter for prostate and bladder cancer patients (OR 4.10, 95% CI 1.4511.58; OR 3.42, 95% CI 1.09-10.77). CONCLUSION The lower rates of telemedicine use among Black patients could exacerbate pre-existing disparities in prostate, bladder, and kidney cancer outcomes.
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Affiliation(s)
- Zeynep G Gul
- Department of Surgery, Division of Urology, University of Washington in St. Louis, St. Louis, MO.
| | - Danielle R Sharbaugh
- Department of Urology, Division of Health Services Research, University of Pittsburgh, Pittsburgh, PA
| | - Chad Ellimoottil
- Department of Urology, University of Michigan, Ann Arbor, MI; Institute for Healthcare Policy and Innovation, Ann Arbor, MI
| | - Kimberly J Rak
- Department of Critical Care Medicine, Clinical Research, Investigation, and Systems Modeling of Acute Illness Center, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Jonathan G Yabes
- Department of Medicine, University of Pittsburgh, Pittsburgh, PA
| | - Benjamin J Davies
- Department of Urology, Division of Health Services Research, University of Pittsburgh, Pittsburgh, PA
| | - Bruce L Jacobs
- Department of Urology, Division of Health Services Research, University of Pittsburgh, Pittsburgh, PA
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Dember LM, Hsu JY, Bernardo L, Cavanaugh KL, Charytan DM, Crowley ST, Cukor D, Doorenbos AZ, Edwards DA, Esserman D, Fischer MJ, Jhamb M, Joffe S, Johansen KL, Kalim S, Keefe FJ, Kimmel PL, Krebs EE, Kuzla N, Mehrotra R, Mishra P, Pellegrino B, Steel JL, Unruh ML, White DM, Yabes JG, Becker WC. The design and baseline characteristics for the HOPE Consortium Trial to reduce pain and opioid use in hemodialysis. Contemp Clin Trials 2024; 136:107409. [PMID: 38086444 PMCID: PMC10922728 DOI: 10.1016/j.cct.2023.107409] [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: 08/11/2023] [Revised: 11/07/2023] [Accepted: 12/06/2023] [Indexed: 01/07/2024]
Abstract
The HOPE Consortium Trial to Reduce Pain and Opioid Use in Hemodialysis (HOPE Trial) is a multicenter randomized trial addressing chronic pain among patients receiving maintenance hemodialysis for end-stage kidney disease. The trial uses a sequential, multiple assignment design with a randomized component for all participants (Phase 1) and a non-randomized component for a subset of participants (Phase 2). During Phase 1, participants are randomized to Pain Coping Skills Training (PCST), an intervention designed to increase self-efficacy for managing pain, or Usual Care. PCST consists of weekly, live, coach-led cognitive behavioral therapy sessions delivered by video- or tele-conferencing for 12 weeks followed by daily interactive voice response sessions delivered by telephone for an additional 12 weeks. At 24 weeks (Phase 2), participants in both the PCST and Usual Care groups taking prescription opioid medications at an average dose of ≥20 morphine milligram equivalents per day are offered buprenorphine, a partial opioid agonist with a more favorable safety profile than full-agonist opioids. All participants are followed for 36 weeks. The primary outcome is pain interference ascertained, for the primary analysis, at 12 weeks. Secondary outcomes include additional patient-reported measures and clinical outcomes including falls, hospitalizations, and death. Exploratory outcomes include acceptability, tolerability, and efficacy of buprenorphine. The enrollment target of 640 participants was met 27 months after trial initiation. The findings of the trial will inform the management of chronic pain, a common and challenging issue for patients treated with maintenance hemodialysis. NCT04571619.
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Affiliation(s)
- Laura M Dember
- Renal-Electrolyte and Hypertension Division, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States of America; Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States of America; Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States of America.
| | - Jesse Y Hsu
- Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States of America; Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States of America
| | - Leah Bernardo
- Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States of America
| | - Kerri L Cavanaugh
- Division of Nephrology & Hypertension, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, United States of America
| | - David M Charytan
- Nephrology Division, Department of Medicine, New York University Grossman School of Medicine, and NYU Langone Health, New York, NY, United States of America
| | - Susan T Crowley
- Section of Nephrology, Department of Medicine, Yale School of Medicine, New Haven, CT, United States of America; Kidney Medicine Program, Medical Services, VA Connecticut Healthcare System, West Haven, CT, United States of America
| | - Daniel Cukor
- Behavioral Health, The Rogosin Institute, New York, NY, United States of America
| | - Ardith Z Doorenbos
- College of Nursing, University of Illinois Chicago, Chicago, IL, United States of America
| | - David A Edwards
- Division of Pain Medicine, Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN, United States of America
| | - Denise Esserman
- Department of Biostatistics, Yale School of Public Health, New Haven, CT, United States of America
| | - Michael J Fischer
- Department of Medicine, University of Illinois Chicago, Chicago, IL, United States of America; Medical Service, Jesse Brown VA Medical Center, Chicago, IL, United States of America; Center of Innovation for Complex Chronic Healthcare, Edward Hines Jr. VA Hospital, Hines, IL, United States of America
| | - Manisha Jhamb
- Renal and Electrolyte Division, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States of America
| | - Steven Joffe
- Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States of America
| | - Kirsten L Johansen
- Nephrology Division, Hennepin Healthcare, Department of Medicine, University of Minnesota, Minneapolis, MN, United States of America
| | - Sahir Kalim
- Department of Medicine, Division of Nephrology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, United States of America
| | - Francis J Keefe
- Pain Prevention and Treatment Research Program, Department of Psychiatry and Behavioral Sciences, Duke University School of Medicine, Durham, NC, United States of America
| | - Paul L Kimmel
- Division of Kidney, Urologic, and Hematologic Diseases, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, MD, United States of America
| | - Erin E Krebs
- General Internal Medicine, Minneapolis VA Health Care System, University of Minnesota Medical School, Minneapolis, MN, United States of America
| | - Natalie Kuzla
- Clinical Research Computing Unit, Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States of America
| | - Rajnish Mehrotra
- Kidney Research Institute, Division of Nephrology, Department of Medicine, University of Washington School of Medicine, Seattle, WA, United States of America
| | - Puneet Mishra
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN, United States of America
| | - Bethany Pellegrino
- Division of Nephrology, Department of Medicine, West Virginia University School of Medicine, Morgantown, WV, United States of America
| | - Jennifer L Steel
- Division of Hepatobiliary Surgery, Department of Surgery, Psychiatry, and Psychology, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States of America
| | - Mark L Unruh
- Division of Nephrology, Department of Internal Medicine, University of New Mexico School of Medicine, Albuquerque, NM, United States of America; Research Service, Department of Medicine, Raymond G. Murphy Veterans Affairs Medical Center and University of New Mexico School of Medicine, Albuquerque, NM, United States of America
| | - David M White
- American Association of Kidney Patients, Tampa, FL, United States of America
| | - Jonathan G Yabes
- Division of General Internal Medicine, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States of America
| | - William C Becker
- Section of General Internal Medicine, Department of Medicine, Yale School of Medicine, New Haven, CT, United States of America; Pain Research, Informatics, Multi-morbidities & Education Center of Innovation, VA Connecticut Healthcare System, West Haven, CT, United States of America
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Myrga JM, Erpenbeck SP, Watts A, Stencel MG, Staniorski CJ, Patnaik S, Yabes JG, Yu M, Allaway MJ, Gorin MA, Jacobs BL, Davies BJ. Patient Reported Outcomes of Transperineal Prostate Biopsy With Tumescent Local Anesthesia. Urology 2023; 182:33-39. [PMID: 37742847 DOI: 10.1016/j.urology.2023.09.010] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2023] [Revised: 08/01/2023] [Accepted: 09/12/2023] [Indexed: 09/26/2023]
Abstract
OBJECTIVE To report the outcomes of performing transperineal prostate biopsy in the office setting using the novel anesthetic technique of tumescent local anesthesia. We report anxiety, pain, and embarrassment of patients who underwent this procedure compared to patients who underwent a transrectal prostate biopsy using standard local anesthesia. MATERIALS AND METHODS Consecutive patients undergoing either a transperineal prostate biopsy under tumescent local anesthesia or a transrectal prostate biopsy with standard local anesthetic technique were prospectively enrolled. The tumescent technique employed dilute lidocaine solution administered using a self-filling syringe. Patients were asked to rate their pain before, during, and after their procedure using a visual analog scale. Patient anxiety and embarrassment was assessed using the Testing Modalities Index Questionnaire. RESULTS Between April 2021 and June 2022, 430 patients underwent a transperineal prostate biopsy using tumescent local anesthesia and 65 patients underwent a standard transrectal prostate biopsy. Patients who underwent a transperineal biopsy had acceptable but significantly higher pain scores than those who underwent a transrectal prostate biopsy (3.9 vs 1.6, P-value <.01). These scores fell to almost zero immediately following their procedure. Additionally, transperineal biopsy patients were more likely to experience anxiety (71% vs 45%, P < .01) and embarrassment (32% vs 15%, P < .01). CONCLUSION Transperineal biopsy using local tumescent anesthesia is safe and well-tolerated. Despite the benefits, patients undergoing a transperineal prostate biopsy under tumescent anesthesia still experienced worse procedural pain, anxiety, and embarrassment. Additional studies examining other adjunctive interventions to improve patient experience during transperineal prostate biopsy are needed.
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Affiliation(s)
- John M Myrga
- University of Pittsburgh Medical Center, Division of Health Services Research, Department of Urology, Pittsburgh, PA.
| | | | - Alexander Watts
- University of Pittsburgh Medical Center, Division of Health Services Research, Department of Urology, Pittsburgh, PA
| | - Michael G Stencel
- University of Pittsburgh Medical Center, Division of Health Services Research, Department of Urology, Pittsburgh, PA
| | - Christopher J Staniorski
- University of Pittsburgh Medical Center, Division of Health Services Research, Department of Urology, Pittsburgh, PA
| | - Shyam Patnaik
- University of Pittsburgh Medical Center, Division of Health Services Research, Department of Urology, Pittsburgh, PA
| | - Jonathan G Yabes
- Department of Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Michelle Yu
- University of Pittsburgh Medical Center, Division of Health Services Research, Department of Urology, Pittsburgh, PA
| | | | - Michael A Gorin
- Milton and Carroll Petrie Department of Urology at the Icahn School of Medicine at Mount Sinai, New York City, NY
| | - Bruce L Jacobs
- University of Pittsburgh Medical Center, Division of Health Services Research, Department of Urology, Pittsburgh, PA
| | - Benjamin J Davies
- University of Pittsburgh Medical Center, Division of Health Services Research, Department of Urology, Pittsburgh, PA
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10
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Gul ZG, Wu S, Raver M, Vasan R, Mihalo J, Myrga JM, Miller DT, Pere MP, Jones CA, Sharbaugh DR, Yabes JG, Jacobs BL, Davies BJ. A Multipronged Intervention to Reduce Readmissions and Readmission Intensity After Radical Cystectomy. Urology 2023; 182:155-160. [PMID: 37666330 DOI: 10.1016/j.urology.2023.08.012] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2023] [Revised: 08/15/2023] [Accepted: 08/16/2023] [Indexed: 09/06/2023]
Abstract
OBJECTIVE To develop a multipronged, evidence-based protocol to reduce readmission risk and readmission intensity, as represented by the duration of the index readmission, after radical cystectomy. MATERIALS AND METHODS A per-protocol study was performed. The protocol included preoperative nutritional supplementation, early stent removal, and a follow-up phone call within 4-5days of discharge. The preprotocol period was from February 1, 2020 to July 31, 2021 and the postprotocol period was from December 1, 2020 to November 31, 2021. Using multivariate regression models, we compared outcomes among patients treated with radical cystectomy before and after protocol initiation. RESULTS We identified 70 preprotocol patients and 126 postprotocol patients. After adjusting for age, sex, BMI, and frailty score, there was a significant reduction in 90-day readmission intensity (7 vs 5days; P = .048) among postprotocol patients. CONCLUSION After implementation of an evidence-based protocol for patients undergoing radical 90-day readmission intensity decreased significantly. This protocol may move the needle forward on reducing readmissions, but a larger randomized trial is needed.
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Affiliation(s)
- Zeynep G Gul
- Univserity of Washington in St. Louis, Department of Surgery, Division of Urology, St. Louis, MO.
| | - Shan Wu
- University of Pittsburgh, Department of Urology, Pittsburgh, PA
| | - Michael Raver
- University of Pittsburgh, School of Medicine, Pittsburgh, PA
| | - Robin Vasan
- University of Pittsburgh, Department of Urology, Pittsburgh, PA
| | - Jennifer Mihalo
- University of Pittsburgh, School of Medicine, Pittsburgh, PA
| | - John M Myrga
- University of Pittsburgh, Department of Urology, Pittsburgh, PA
| | - David T Miller
- University of Pittsburgh, Department of Urology, Pittsburgh, PA
| | - Maria P Pere
- University of Pittsburgh, Department of Urology, Pittsburgh, PA
| | - Cameron A Jones
- University of Pittsburgh, Department of Urology, Pittsburgh, PA
| | | | | | - Bruce L Jacobs
- University of Pittsburgh, Department of Urology, Pittsburgh, PA
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11
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Jhamb M, Devaraj SM, Alemairi M, Lavenburg LM, Shiva S, Yabes JG, Forman DE, Hergenroeder AL. A Comprehensive Exercise (COMEX) Intervention to Optimize Exercise Participation for Improving Patient-Centered Outcomes and Physical Functioning in Patients Receiving Hemodialysis: Development and Pilot Testing. Kidney Med 2023; 5:100720. [PMID: 37928754 PMCID: PMC10623365 DOI: 10.1016/j.xkme.2023.100720] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2023] Open
Abstract
Rationale & Objective To address the need for an intradialytic exercise program that is easily delivered in clinical setting, engaging and scalable, we developed a novel COMprehensive EXercise (COMEX) program based on input from patients receiving hemodialysis (HD), dialysis staff members and nephrologists. The objective of this study was to determine the feasibility, safety, and acceptance of COMEX during HD. Study Design Single-arm prospective pilot feasibility study. Setting & Participants Seventeen patients receiving in-center HD. Intervention Three-month participation in the COMEX program, which included video-based dialysis chair exercises (aerobic and resistance) integrated with educational and motivational components. Outcomes Data on recruitment, adherence, safety and acceptability were collected. Additional assessments were performed to evaluate changes in physical functioning, patient-reported symptoms, and objectively measured sleep and physical activity. We also examined the feasibility of obtaining skeletal muscle biopsies and blood samples to explore molecular mechanisms of muscle atrophy and to assess platelet mitochondrial function and adaptation to exercise during HD. Results Thirteen of the 17 (76%) participants completed the 3-month intervention. The mean participant age was 63.6 ± 15.1 years. In total, 46% of participants were males, and 55% were White. The mean body mass index was 38.7 ± 11.6 kg/m2. There were no reported adverse effects, and the adherence rate to exercise sessions was high with 88% of the sessions completed. Patient satisfaction was high, as 100% of the patients would recommend the program to other dialysis patients. It was feasible to collect data on physical functioning, patient-reported symptoms, and objective sleep and physical activity and to obtain muscle biopsies and blood samples. Limitations Small sample size, lack of an onsite exercise professional, and technological issues with telemedicine behavioral motivation. Conclusions The COMEX intradialytic exercise intervention is safe and acceptable to patients, and outcome measures were feasible to obtain. Future studies should consider including exercise professionals to facilitate progression through a personalized exercise protocol. Funding Source This work is supported by pilot award from P30 DK079307 (PI, Jhamb). Trial Registration ClinicalTrials.gov, NCT03055299. Plain-Language Summary We tested a new COMprehensive EXercise (COMEX) program to deliver exercise during dialysis. This 3-month program included video-based dialysis chair exercises (aerobic and resistance) integrated with educational and motivational components. Our study shows COMEX was feasible, had high satisfaction and adherence, and was safe. It was feasible to collect data on physical functioning, patient-reported symptoms, and objective sleep and physical activity and to obtain muscle biopsies and blood samples. Future studies should consider including exercise professionals to facilitate progression through a personalized exercise protocol.
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Affiliation(s)
- Manisha Jhamb
- Renal-Electrolyte Division, Department of Medicine, University of Pittsburgh, Pittsburgh, PA
| | - Susan M. Devaraj
- Renal-Electrolyte Division, Department of Medicine, University of Pittsburgh, Pittsburgh, PA
| | - Maryam Alemairi
- School of Health and Rehabilitation Sciences, University of Pittsburgh, Pittsburgh, PA
- Kuwait University, Kuwait City, Kuwait
| | - Linda-Marie Lavenburg
- Renal-Electrolyte Division, Department of Medicine, University of Pittsburgh, Pittsburgh, PA
| | - Sruti Shiva
- Vascular Medicine Institute, Department of Medicine and Department of Pharmacology and Chemical Biology, University of Pittsburgh, Pittsburgh, PA
| | - Jonathan G. Yabes
- Center for Research on Health Care Data Center, Division of General Internal Medicine, Department of Medicine and Biostatistics, University of Pittsburgh, Pittsburgh, PA
| | - Daniel E. Forman
- Department of Medicine (Divisions of Geriatrics and Cardiology), University of Pittsburgh, and Pittsburgh Geriatrics, Research, Education, and Clinical Center (GRECC), VA Pittsburgh Healthcare System, Pittsburgh, PA
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12
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Stencel MG, MacLeod L, Yabes JG, Yu M, Davies BJ, Jacobs BL. Partial Nephrectomy Drives the Association Between High-volume Centers and Decreased Mortality: A Surveillance, Epidemiology, and End Results-Medicare Analysis. Urology 2023; 181:55-62. [PMID: 37544519 DOI: 10.1016/j.urology.2023.07.026] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2023] [Revised: 06/05/2023] [Accepted: 07/18/2023] [Indexed: 08/08/2023]
Abstract
OBJECTIVE To better understand the association between high-volume surgical kidney cancer centers and decreased mortality. To identify quality metrics that mediate this association. METHODS We designed a cohort of 14,044 patients who were diagnosed with kidney cancer between 2004 and 2013 and underwent a partial or radical nephrectomy using SEER-Medicare data. Hospitals were divided into quartiles based on their total nephrectomy volume for the study period. We investigated 6 quality metrics as potential mediators of the association between hospital volume and mortality using a mediation model. RESULTS At the highest volume centers, survival was higher at 1-, 3-, 5-, and 10-year time intervals, respectively (91% vs 89%, 80% vs 76%, 70% vs 66%, 45% vs 38%, P < .001) compared to the lowest quartile nephrectomy centers. Receipt of partial nephrectomy for stage ≤T1a tumors explains 52.3% of the total association between hospital nephrectomy volume and mortality. Additionally, patients at the highest-volume centers were more likely to be younger (20% vs 26% 80≤ years old, P < .001), white (82% vs 78%, P < .001), reside in more densely populated counties (≥1 million residents, 62% vs 42%, P > .001), have a shorter mean length of stay (5.03 vs 5.88days, P < .001) when compared to those in the lowest-volume quartile. CONCLUSION This analysis of SEER-Medicare data is the first to suggest that partial nephrectomy in the setting of T1a tumors mediates the association between hospital volume and mortality. Quality metrics that reduce mortality should be harnessed to develop more efficient and higher-quality health systems.
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Affiliation(s)
- Michael G Stencel
- University of Pittsburgh Medical Center, Department of Urology, Division of Health Services Research, Pittsburgh, PA.
| | - Liam MacLeod
- Asante Rogue Regional Medical Center, Department of Urology, Medford, OR
| | - Jonathan G Yabes
- Center for Research on Heath Care Data Center, Department of Medicine and Biostatistics, Pittsburgh, PA
| | - Michelle Yu
- University of Pittsburgh Medical Center, Department of Urology, Division of Health Services Research, Pittsburgh, PA
| | - Benjamin J Davies
- University of Pittsburgh Medical Center, Department of Urology, Division of Health Services Research, Pittsburgh, PA
| | - Bruce L Jacobs
- University of Pittsburgh Medical Center, Department of Urology, Division of Health Services Research, Pittsburgh, PA
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13
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Reed KG, Sun Z, Yabes JG, Drake C, Ober N, Jacobs B, van Londen GJ, Bradley CJ, Sabik LM. Assessing characteristics of populations seen at Commission on Cancer facilities using Pennsylvania linked data. JNCI Cancer Spectr 2023; 7:pkad080. [PMID: 37788093 PMCID: PMC10627003 DOI: 10.1093/jncics/pkad080] [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] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2023] [Revised: 08/11/2023] [Accepted: 09/25/2023] [Indexed: 10/05/2023] Open
Abstract
Commission on Cancer (CoC) accreditation certifies facilities provide quality care. We assessed differences among patients who do and do not visit CoC facilities using Pennsylvania Cancer Registry data linked to facility records for patients diagnosed with cancer between 2018 and 2019 (n = 87 472). Predicted probabilities from multivariable logistic regression indicated patients in the most advantaged Area Deprivation Index quartiles were more likely to visit CoC facilities (78.0%, 95% confidence interval [CI] = 77.5% to 78.6%) compared with other quartiles. Urban patients (74.1%, 95% CI = 73.8% to 74.4%) were more likely than rural to be seen at a CoC facility (62.7%, 95% CI = 61.2% to 64.2%) as were Hispanic patients (88.0%, 95% CI = 86.7% to 89.3%) and non-Hispanic Black patients (79.1%, 95% CI = 78.1% to 80.0%) compared with White patients (72.0%, 95% CI = 71.7% to 72.4%). Differences in demographics suggest CoC data may underrepresent some groups, including low-income and rural patients.
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Affiliation(s)
- Kristine G Reed
- Division of Hematology/Oncology, Department of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
- Shenandoah Oncology, Winchester, VA, USA
| | - Zhaojun Sun
- Department of Health Policy and Management, School of Public Health, University of Pittsburgh, Pittsburgh, PA, USA
| | - Jonathan G Yabes
- Division of General Internal Medicine, Department of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
- Department of Biostatistics, School of Public Health, University of Pittsburgh, Pittsburgh, PA, USA
| | - Coleman Drake
- Department of Health Policy and Management, School of Public Health, University of Pittsburgh, Pittsburgh, PA, USA
| | - Nicole Ober
- Department of Health Policy and Management, School of Public Health, University of Pittsburgh, Pittsburgh, PA, USA
| | - Bruce Jacobs
- Division of Health Services Research, Department of Urology, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | | | - Cathy J Bradley
- University of Colorado Comprehensive Cancer Center, Aurora, CO, USA
- Department of Health Systems, Management & Policy, Colorado School of Public Health, Aurora, CO, USA
| | - Lindsay M Sabik
- Department of Health Policy and Management, School of Public Health, University of Pittsburgh, Pittsburgh, PA, USA
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Zarka J, Jeong K, Yabes JG, Ragni MV. Prevalence and risk factors for bleeding in hereditary hemorrhagic telangiectasia: a National Inpatient Sample study. Blood Adv 2023; 7:5843-5850. [PMID: 37567149 PMCID: PMC10561038 DOI: 10.1182/bloodadvances.2023010743] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2023] [Revised: 07/12/2023] [Accepted: 07/12/2023] [Indexed: 08/13/2023] Open
Abstract
Hereditary hemorrhagic telangiectasia (HHT) is a common bleeding disorder, but little is known regarding prevalence and risk factors for bleeding. Adult discharges with HHT and bleeding were identified by International Classification of Disease, 10th edition (ICD-10) codes in the National Inpatient Sample (NIS), 2016-2018. Prevalence estimates were weighted using NIS discharge-level weights to reflect national estimates. Risk factors for bleeding were determined by weighted multivariable logistic regression. Among 18 170 849 discharges, 2528 (0.01%) had HHT, of whom 648 (25.6%) had bleeding. Arteriovenous malformation (AVM) (31.9% vs 1.3%), angiodysplasia (23.5% vs 2.3%), telangiectasia (2.3% vs 0.2%), and epistaxis (17.9% vs 0.6%) were more common in HHT than in non-HHT patients (non-HHT), each P < .001. In contrast, menstrual (HMB) and postpartum bleeding (PPH) were less common in reproductive-age HHT than non-HHT, each P < .001. Anemia associated with iron deficiency (IDA), was equally common in HHT with or without bleeding (15.7% vs 16.0%), but more common than in non-HHT (7.5%), P < .001. Comorbidities, including gastroesophageal reflux (25.9% vs 20.0%) and cirrhosis (10.0% vs 3.6%) were greater in HHT than non-HHT, each P < .001. In multivariable logistic regression, peptic ulcer disease (OR, 8.86; P < .001), portal vein thrombosis (OR, 3.68; P = .006), and hepatitis C, (OR, 2.13; P = .017) were significantly associated with bleeding in HHT. In conclusion, AVM and angiodysplasia are more common and HMB and PPH less common in patients in those with HHT than non-HHT. IDA deficiency is as common in HHT with and without bleeding, suggesting ongoing blood loss and need for universal iron screening.
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Affiliation(s)
- Jabra Zarka
- Department of Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Kwonho Jeong
- University of Pittsburgh Center for Research on Health Care Data Center, Pittsburgh, PA
| | - Jonathan G. Yabes
- University of Pittsburgh Center for Research on Health Care Data Center, Pittsburgh, PA
| | - Margaret V. Ragni
- Department of Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA
- Division of Hematology/Oncology, Department of Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA
- Hemophilia Center of Western Pennsylvania, Pittsburgh, PA
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15
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Devaraj SM, Roumelioti ME, Yabes JG, Schopp M, Erickson S, Steel JL, Rollman BL, Weisbord SD, Unruh M, Jhamb M. Correlates of Rates and Treatment Readiness for Depressive Symptoms, Pain, and Fatigue in Hemodialysis Patients: Results from the TĀCcare Study. Kidney360 2023; 4:e1265-e1275. [PMID: 37461138 PMCID: PMC10547226 DOI: 10.34067/kid.0000000000000213] [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] [Subscribe] [Scholar Register] [Received: 01/26/2023] [Revised: 05/23/2023] [Accepted: 07/10/2023] [Indexed: 09/29/2023]
Abstract
Key Points Lower neighborhood walkability was associated with higher depressive symptoms and fatigue and younger age with depressive symptoms. Depressive symptoms, pain, and fatigue were frequently reported, often occurred together, and were often not all already treated. Patients with a higher symptom burden and men may be more likely to be ready to seek treatment for depressive symptoms, pain, or fatigue. Background Patients on hemodialysis (HD) often experience clinically significant levels of pain, fatigue, and depressive symptoms. We explored potential sociodemographic differences in symptom burden, current treatment, and readiness to seek treatment for these symptoms in patients screened for the TĀCcare trial. Methods In-center HD patients from Pennsylvania and New Mexico were screened for fatigue (≥5 on 0–10-point Likert scale), pain (Likert scale ≥4), depressive symptoms (≥10 Patient Health Questionnaire-9), and readiness to seek treatment (5–item Stages of Behavior Change questionnaire). Symptom burden and treatment status by sociodemographic factors were evaluated using chi square, Fisher exact tests, and logistic regression models. Results From March 2018 to December 2021, 506 of 896 (57%) patients screened met eligibility criteria and completed the symptom screening (mean age 60±13.9 years, 44% female, 17% Black, 25% American Indian, and 25% Hispanics). Of them, 77% screened positive for ≥1 symptom and 35% of those were receiving treatment for ≥1 of these symptoms. Pain, fatigue, and depressive symptom rates were 52%, 64%, and 24%, respectively. Age younger than 65 years was associated with a higher burden of depressive symptoms, pain, and reporting ≥1 symptom (P <0.05). The percentage of patients ready to seek treatment increased with symptom burden. More men reported readiness to seek treatment (85% versus 68% of women, P <0.001). Among those with symptoms and treatment readiness, income was inversely associated with pain (>$60,000/yr: odds ratio [OR]=0.16, confidence interval [CI]=0.03 to 0.76) and living in less walkable neighborhoods with more depressive symptoms (OR= 5.34, CI=1.19 to 24.05) and fatigue (OR= 5.29, CI=1.38 to 20.33). Conclusions Pain, fatigue, and depressive symptoms often occurred together, and younger age, less neighborhood walkability, and lower income were associated with a higher burden of symptoms in HD patients. Male patients were less likely to be receiving treatment for symptoms. These findings could inform priority HD patient symptom identification and treatment targets.
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Affiliation(s)
- Susan M. Devaraj
- Renal-Electrolyte Division, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Maria-Eleni Roumelioti
- Division of Nephrology, Department of Internal Medicine, University of New Mexico School of Medicine, Albuquerque, New Mexico
| | - Jonathan G. Yabes
- Center for Research on Heath Care Data Center, Division of General Internal Medicine; Department of Medicine and Biostatistics, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Mary Schopp
- Renal-Electrolyte Division, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Sarah Erickson
- Department of Psychology, University of New Mexico, Albuquerque, New Mexico
| | - Jennifer L. Steel
- Department of Surgery, Psychiatry and Psychology, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Bruce L. Rollman
- Center for Behavioral Health, Media, and Technology, Division of General Internal Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Steven D. Weisbord
- Renal Section and Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
| | - Mark Unruh
- Division of Nephrology, Department of Internal Medicine, University of New Mexico School of Medicine, Albuquerque, New Mexico
| | - Manisha Jhamb
- Renal-Electrolyte Division, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
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Jhamb M, Weltman MR, Yabes JG, Kamat S, Devaraj SM, Fischer GS, Rollman BL, Nolin TD, Abdel-Kader K. Electronic health record based population health management to optimize care in CKD: Design of the Kidney Coordinated HeAlth Management Partnership (K-CHAMP) trial. Contemp Clin Trials 2023; 131:107269. [PMID: 37348600 PMCID: PMC10529809 DOI: 10.1016/j.cct.2023.107269] [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: 01/20/2023] [Revised: 06/06/2023] [Accepted: 06/19/2023] [Indexed: 06/24/2023]
Abstract
Primary care physicians (PCPs) provide the majority of medical care to patients with non-dialysis dependent CKD. However, PCPs report numerous limitations to providing expert CKD care, including poor patient education, inadequate diagnostic evaluation, suboptimal use of medications, and time limitations. The Kidney Coordinated HeAlth Management Partnership (Kidney CHAMP) trial is a cluster randomized controlled trial to evaluate the effectiveness of a novel centralized electronic health records (EHR)-delivered population health management (PHM) strategy for high-risk CKD patients on patient care, safety, and other outcomes of interest to patients, providers, and payors. Over a 42-month period, the trial will compare the effectiveness of a multifaceted intervention that combines early identification of high-risk patients, timely nephrology guidance, pharmacist-led medication management services, and CKD patient education to usual care and enroll 1650 high-risk CKD patients from 100 primary care practices. The primary outcome will be ≥40% decline in estimated glomerular filtration rate (eGFR) or end stage kidney disease. Key secondary outcomes will include blood pressure, renin-angiotensin aldosterone system inhibitors use, and exposure to potentially unsafe medications. If successful, our treatment approach could improve CKD care delivery and safety, resource allocation, and adoption of evidence-based CKD guideline-concordant care.
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Affiliation(s)
- Manisha Jhamb
- Renal and Electrolyte Division, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States of America.
| | - Melanie R Weltman
- Renal-Electrolyte Division, University of Pittsburgh Medical Center, Pittsburgh, PA, United States of America
| | - Jonathan G Yabes
- Center for Research on Heath Care, Division of General Internal Medicine, Department of Medicine and Biostatistics, University of Pittsburgh, Pittsburgh, PA, United States of America
| | - Sanjana Kamat
- Renal and Electrolyte Division, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States of America
| | - Susan M Devaraj
- Renal and Electrolyte Division, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States of America
| | - Gary S Fischer
- Department of Medicine and Biomedical Informatics, University of Pittsburgh, Pittsburgh, PA, United States of America
| | - Bruce L Rollman
- Center for Research on Heath Care, Division of General Internal Medicine, Department of Medicine and Biostatistics, University of Pittsburgh, Pittsburgh, PA, United States of America; Center for Behavioral Health, Media, and Technology, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States of America
| | - Thomas D Nolin
- Renal and Electrolyte Division, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States of America; Department of Pharmacy and Therapeutics, University of Pittsburgh School of Pharmacy, Pittsburgh, PA, United States of America
| | - Khaled Abdel-Kader
- Division of Nephrology and Hypertension, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, United States of America
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17
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Jhamb M, Steel JL, Yabes JG, Roumelioti ME, Erickson S, Devaraj SM, Vowles KE, Vodovotz Y, Beach S, Weisbord SD, Rollman BL, Unruh M. Effects of Technology Assisted Stepped Collaborative Care Intervention to Improve Symptoms in Patients Undergoing Hemodialysis: The TĀCcare Randomized Clinical Trial. JAMA Intern Med 2023; 183:795-805. [PMID: 37338898 PMCID: PMC10282960 DOI: 10.1001/jamainternmed.2023.2215] [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: 03/07/2023] [Accepted: 04/15/2023] [Indexed: 06/21/2023]
Abstract
Importance Patients with end-stage kidney disease (ESKD) undergoing long-term hemodialysis often experience a high burden of debilitating symptoms for which effective treatment options are limited. Objective To compare the effectiveness of a stepped collaborative care intervention vs attention control for reducing fatigue, pain, and depression among patients with ESKD undergoing long-term hemodialysis. Design, Setting, and Participants Technology Assisted Stepped Collaborative Care (TĀCcare) was a parallel-group, single-blinded, randomized clinical trial of adult (≥18 years) patients undergoing long-term hemodialysis and experiencing clinically significant levels of fatigue, pain, and/or depression for which they were considering treatment. The trial took place in 2 US states (New Mexico and Pennsylvania) from March 1, 2018, to June 31, 2022. Data analyses were performed from July 1, 2022, to April 10, 2023. Interventions The intervention group received 12 weekly sessions of cognitive behavioral therapy delivered via telehealth in the hemodialysis unit or patient home, and/or pharmacotherapy using a stepped approach in collaboration with dialysis and primary care teams. The attention control group received 6 telehealth sessions of health education. Main Outcomes and Measures The coprimary outcomes were changes in fatigue (measured using the Functional Assessment of Chronic Illness Therapy Fatigue), average pain severity (Brief Pain Inventory), and/or depression (Beck Depression Inventory-II) scores at 3 months. Patients were followed up for 12 months to assess maintenance of intervention effects. Results There were 160 participants (mean [SD] age, 58 [14] years; 72 [45%] women and 88 [55%] men; 21 [13%] American Indian, 45 [28%] Black, 28 [18%] Hispanic, and 83 [52%] White individuals) randomized, 83 to the intervention and 77 to the control group. In the intention-to-treat analyses, when compared with controls, patients in the intervention group experienced statistically and clinically significant reductions in fatigue (mean difference [md], 2.81; 95% CI, 0.86 to 4.75; P = .01) and pain severity (md, -0.96; 95% CI, -1.70 to -0.23; P = .02) at 3 months. These effects were sustained at 6 months (md, 3.73; 95% CI, 0.87 to 6.60; P = .03; and BPI, -1.49; 95% CI, -2.58 to -0.40; P = .02). Improvement in depression at 3 months was statistically significant but small (md -1.73; 95% CI, -3.18 to -0.28; P = .02). Adverse events were similar in both groups. Conclusions and Relevance This randomized clinical trial found that a technology assisted stepped collaborative care intervention delivered during hemodialysis led to modest but clinically meaningful improvements in fatigue and pain at 3 months vs the control group, with effects sustained until 6 months. Trial Registration ClinicalTrials.gov Identifier: NCT03440853.
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Affiliation(s)
- Manisha Jhamb
- Renal-Electrolyte Division, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Jennifer L. Steel
- Department of Surgery, Psychiatry and Psychology, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Jonathan G. Yabes
- Center for Research on Heath Care Data Center, Division of General Internal Medicine, Department of Medicine and Biostatistics, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Maria-Eleni Roumelioti
- Division of Nephrology, Department of Internal Medicine, University of New Mexico School of Medicine Albuquerque
| | - Sarah Erickson
- Department of Psychology, University of New Mexico, Albuquerque
| | - Susan M. Devaraj
- Renal-Electrolyte Division, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Kevin E. Vowles
- School of Psychology, Queen’s University, Belfast, Northern Ireland, United Kingdom
| | - Yoram Vodovotz
- Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Scott Beach
- Department of Psychology, University Center for Social and Urban Research, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Steven D. Weisbord
- Renal-Electrolyte Division, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
- Renal Section and Center for Health Equity Research and Promotion, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
| | - Bruce L. Rollman
- Center for Behavioral Health, Media, and Technology, Division of General Internal Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Mark Unruh
- Division of Nephrology, Department of Internal Medicine, University of New Mexico School of Medicine Albuquerque
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18
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Kahn JM, Yabes JG, Bukowski LA, Davis BS. Intensivist physician-to-patient ratios and mortality in the intensive care unit. Intensive Care Med 2023; 49:545-553. [PMID: 37133740 PMCID: PMC10155655 DOI: 10.1007/s00134-023-07066-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] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2023] [Accepted: 04/01/2023] [Indexed: 05/04/2023]
Abstract
PURPOSE A high daily census may hinder the ability of physicians to deliver quality care in the intensive care unit (ICU). We sought to determine the relationship between intensivist-to-patient ratios and mortality among ICU patients. METHODS We performed a retrospective cohort study of intensivist-to-patient ratios in 29 ICUs in 10 hospitals in the United States from 2018 to 2020. We used meta-data from progress notes in the electronic health record to determine an intensivist-specific caseload for each ICU day. We then fit a multivariable proportional hazards model with time-varying covariates to estimate the relationship between the daily intensivist-to-patient ratio and ICU mortality at 28 days. RESULTS The final analysis included 51,656 patients, 210,698 patient days, and 248 intensivist physicians. The average caseload per day was 11.8 (standard deviation: 5.7). There was no association between the intensivist-to-patient ratio and mortality (hazard ratio for each additional patient: 0.987, 95% confidence interval: 0.968-1.007, p = 0.2). This relationship persisted when we defined the ratio as caseload over the sample-wide average (hazard ratio: 0.907, 95% confidence interval: 0.763-1.077, p = 0.26) and cumulative days with a caseload over the sample-wide average (hazard ratio: 0.991, 95% confidence interval: 0.966-1.018, p = 0.52). The relationship was not modified by the presence of physicians-in-training, nurse practitioners, and physician assistants (p value for interaction term: 0.14). CONCLUSIONS Mortality for ICU patients appears resistant to high intensivist caseloads. These results may not generalize to ICUs organized differently than those in this sample, such as ICUs outside the United States.
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Affiliation(s)
- Jeremy M Kahn
- CRISMA Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, 602B Allan Magee Scaife Hall, 3550 Terrace Street, Pittsburgh, PA, 15213, USA.
- Department of Health Policy and Management, University of Pittsburgh School of Public Health, Pittsburgh, PA, 15213, USA.
| | - Jonathan G Yabes
- Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
- Department of Biostatistics, University of Pittsburgh School of Public Health, Pittsburgh, PA, USA
| | - Leigh A Bukowski
- CRISMA Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, 602B Allan Magee Scaife Hall, 3550 Terrace Street, Pittsburgh, PA, 15213, USA
| | - Billie S Davis
- CRISMA Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, 602B Allan Magee Scaife Hall, 3550 Terrace Street, Pittsburgh, PA, 15213, USA
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Chun B, Ramian H, Jones C, Vasan R, Yabes JG, Davies BJ, Sabik LM, Jacobs BL. Changes in Urologic Cancer Surgical Volume and Length of Stay During the COVID-19 Pandemic in Pennsylvania. JAMA Netw Open 2023; 6:e239848. [PMID: 37097635 PMCID: PMC10130946 DOI: 10.1001/jamanetworkopen.2023.9848] [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] [Indexed: 04/26/2023] Open
Abstract
Importance Disruptions in cancer surgery during the COVID-19 pandemic led to widespread deferrals and cancellations, creating a surgical backlog that presents a challenge for health care institutions moving into the recovery phase of the pandemic. Objective To describe patterns in surgical volume and postoperative length of stay for major urologic cancer surgery during the COVID-19 pandemic. Design, Setting, and Participants This cohort study identified 24 001 patients 18 years or older from the Pennsylvania Health Care Cost Containment Council database with kidney cancer, prostate cancer, or bladder cancer who received a radical nephrectomy, partial nephrectomy, radical prostatectomy, or radical cystectomy between the first quarter (Q1) of 2016 and Q2 of 2021. Postoperative length of stay and adjusted surgical volumes were compared before and during the COVID-19 pandemic. Main Outcomes and Measures The primary outcome was adjusted surgical volume for radical and partial nephrectomy, radical prostatectomy, and radical cystectomy during the COVID-19 pandemic. The secondary outcome was postoperative length of stay. Results A total of 24 001 patients (mean [SD] age, 63.1 [9.4] years; 3522 women [15%], 19 845 White patients [83%], 17 896 living in urban areas [75%]) received major urologic cancer surgery between Q1 of 2016 and Q2 of 2021. Of these, 4896 radical nephrectomy, 3508 partial nephrectomy, 13 327 radical prostatectomy, and 2270 radical cystectomy surgical procedures were performed. There were no statistically significant differences in patient age, sex, race, ethnicity, insurance status, urban or rural status, or Elixhauser Comorbidity Index scores between patients who received surgery before and patients who received surgery during the pandemic. For partial nephrectomy, a baseline of 168 surgeries per quarter decreased to 137 surgeries per quarter in Q2 and Q3 of 2020. For radical prostatectomy, a baseline of 644 surgeries per quarter decreased to 527 surgeries per quarter in Q2 and Q3 of 2020. However, the likelihood of receiving radical nephrectomy (odds ratio [OR], 1.00; 95% CI, 0.78-1.28), partial nephrectomy (OR, 0.99; 95% CI, 0.77-1.27), radical prostatectomy (OR, 0.85; 95% CI, 0.22-3.22), or radical cystectomy (OR, 0.69; 95% CI, 0.31-1.53) was unchanged. Length of stay for partial nephrectomy decreased from baseline by a mean of 0.7 days (95% CI, -1.2 to -0.2 days) during the pandemic. Conclusions and Relevance This cohort study suggests that partial nephrectomy and radical prostatectomy surgical volume decreased during the peak waves of COVID-19, as did postoperative length of stay for partial nephrectomy.
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Affiliation(s)
- Brian Chun
- Department of Urology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Haleh Ramian
- Department of Health Policy and Management, University of Pittsburgh School of Public Health, Pittsburgh, Pennsylvania
| | - Cameron Jones
- Department of Urology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Robin Vasan
- Department of Urology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Jonathan G Yabes
- Urology Health Services Research Division, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Benjamin J Davies
- Department of Urology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
- Urology Health Services Research Division, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Lindsay M Sabik
- Department of Health Policy and Management, University of Pittsburgh School of Public Health, Pittsburgh, Pennsylvania
| | - Bruce L Jacobs
- Department of Urology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
- Urology Health Services Research Division, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
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20
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Kavalieratos D, Lowers J, Moreines LT, Hoydich ZP, Arnold RM, Yabes JG, Richless C, Ikejiani DZ, Teuteberg W, Pilewski JM. Embedded Specialist Palliative Care in Cystic Fibrosis: Results of a Randomized Feasibility Clinical Trial. J Palliat Med 2023; 26:489-496. [PMID: 36350712 PMCID: PMC10066777 DOI: 10.1089/jpm.2022.0349] [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] [Accepted: 09/14/2012] [Indexed: 11/10/2022] Open
Abstract
Background: Cystic fibrosis (CF) is a progressive genetic disease characterized by multisystem symptom burden. Specialist palliative care (PC), as a model of care, has been shown to be effective in improving quality of life and reducing symptom burden in other conditions, but has not been tested in CF. Objectives: To develop and test the feasibility and acceptability of a specialist PC intervention embedded within an outpatient CF clinic. Design: Single-site, equal-allocation randomized pilot study comparing usual care with addition of four protocolized quarterly visits with a PC nurse practitioner. Participants: Adults with CF age ≥18 years with any of the following: FEV1% predicted ≤50, ≥2 CF-related hospitalizations in the past 12 months, supplemental oxygen use, or noninvasive mechanical ventilation use, and moderate-or-greater severity of any symptoms on the Edmonton Symptom Assessment Scale. Measurements: Randomization rate, intervention visit completion, data completements, participant ratings of intervention acceptability and benefit, and intervention delivery fidelity. Results: We randomized 50 adults with CF of 65 approached (77% randomization rate) to intervention (n = 25) or usual care (n = 25), mean age 38, baseline mean FEV1% predicted 41.8 (usual care), and 41.2 (intervention). No participants withdrew, five were lost to follow-up, and two died (88% retention). In the intervention group, 23 of 25 completed all study visits; 94% stated the intervention was not burdensome, and 97.6% would recommend the intervention to others with CF. More than 90% of study visits addressed topics prescribed by intervention manual. Conclusions: Adding specialist PC to standard clinic visits for adults with CF is feasible and acceptable.
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Affiliation(s)
| | - Jane Lowers
- Emory University School of Medicine, Atlanta, Georgia, USA
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21
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Gul ZG, Yu M, Sharbaugh DR, Pekala KR, Lin JY, Sharbaugh AJ, Zhu TS, Worku H, Armann KM, Hudson CN, Hay JM, Grajales V, Yabes JG, Davies BJ, Jacobs BL. Utilizing a Questionnaire to Implement a Risk-Based Antibiotic Prophylaxis Protocol for Transrectal Prostate Biopsy. Urology 2023:S0090-4295(23)00147-4. [PMID: 36868411 DOI: 10.1016/j.urology.2022.11.058] [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] [Subscribe] [Scholar Register] [Received: 05/05/2022] [Revised: 10/20/2022] [Accepted: 11/06/2022] [Indexed: 03/05/2023]
Abstract
OBJECTIVE To develop and evaluate a risk-based antibiotic prophylaxis protocol for patients undergoing transrectal prostate biopsy. METHODS We created a risk-based protocol for antibiotic prophylaxis before transrectal prostate biopsy. Patients were screened for infection risk-factors with a self-administered questionnaire. The protocol was implemented from January 1, 2020 to March 31, 2020. We compared patient risk-factors, antibiotic regimens, and 30-day infection rates for patients undergoing transrectal prostate biopsies during the intervention and for a 3-month period before the intervention. RESULTS There were 116 prostate biopsies in the pre-intervention group and 104 in the intervention group. Although there was no significant difference in the number of high-risk patients between the two groups (48% vs 55%; p=0.33), the percentage of patients treated with augmented prophylaxis decreased from 74% to 45% (p=0.03). The duration of antibiotic administration and the median number of doses prescribed also decreased significantly. Despite significant decreases in antibiotic use, there were no differences in infection rates (5% vs 5%; p=0.90) or sepsis rates (1% vs 2%; p=0.60). CONCLUSION We developed a risk-based protocol for prophylactic antibiotics before prostate biopsy. The protocol was associated with less antibiotic use but did not lead to an increase in infectious complications.
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Affiliation(s)
| | - Michelle Yu
- University of Pittsburgh, Department of Urology
| | | | | | | | | | - Toby S Zhu
- University of Pittsburgh, School of Medicine
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22
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Ray KN, Wittman SR, Yabes JG, Sabik LM, Hoberman A, Mehrotra A. Telemedicine Visits to Children During the Pandemic: Practice-Based Telemedicine Versus Telemedicine-Only Providers. Acad Pediatr 2023; 23:265-270. [PMID: 35589062 PMCID: PMC9666718 DOI: 10.1016/j.acap.2022.05.010] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [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: 01/14/2022] [Revised: 05/11/2022] [Accepted: 05/11/2022] [Indexed: 11/29/2022]
Abstract
OBJECTIVE In March 2020, regulatory and payment changes allowed "brick and mortar" pediatric practices to offer practice-based telemedicine for the first time, joining direct-to-consumer (DTC) telemedicine vendors in the ability to offer visits for common acute pediatric concerns via telemedicine. We sought to characterize the relative contribution of practice-based telemedicine versus commercial DTC telemedicine models in provision of children's telemedicine from 2018 through 2021. METHODS Using January 2018 to September 2021 data from Optum's de-identified Clinformatics® Data Mart Database, we identified telemedicine visits by children ≤17, excluding preventive visits and visits to specialists, emergency departments, and urgent care. Among included visits, we defined "telemedicine-only" providers as those with ≥80% of visits via telemedicine and practice-based telemedicine providers as those with ≤50% of visits via telemedicine. We then described the telemedicine visit volume and diagnoses for these categories overall and per 1000 children per month. RESULTS From January 2018 to February 2020, telemedicine-only providers accounted for 57,815 telemedicine visits (90.8%), while practice-based telemedicine accounted for 4192 telemedicine visits (6.6%). From March 2020 to September 2021, telemedicine-only providers accounted for 38,282 telemedicine visits (6.1%), while practice-based telemedicine accounted for 555,125 telemedicine visits (88.2%). Per month, telemedicine visits to practice-based telemedicine providers increased from pre-pandemic to pandemic periods (0.1 vs 12.9 visits per 1000 children/month), while telemedicine visits to telemedicine-only providers occurred at a similar rate from pre-pandemic to pandemic periods (0.92 vs 0.96 visits per 1000 children/month). CONCLUSIONS We observed a large increase in telemedicine visits during the pandemic, with the growth in visits exclusively occurring among visits to practice-based telemedicine providers as opposed to telemedicine-only providers.
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Affiliation(s)
- Kristin N Ray
- Department of Pediatrics (KN Ray, SR Wittman, and A Hoberman), University of Pittsburgh School of Medicine, UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pa.
| | - Samuel R Wittman
- Department of Pediatrics (KN Ray, SR Wittman, and A Hoberman), University of Pittsburgh School of Medicine, UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pa
| | - Jonathan G Yabes
- Department of Medicine (J Yabes), University of Pittsburgh School of Medicine, Pittsburgh, Pa
| | - Lindsay M Sabik
- Department of Health Policy & Management ( L Sabik), University of Pittsburgh Graduate School of Public Health, Pittsburgh, Pa
| | - Alejandro Hoberman
- Department of Pediatrics (KN Ray, SR Wittman, and A Hoberman), University of Pittsburgh School of Medicine, UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pa
| | - Ateev Mehrotra
- Department of Health Care Policy (A Mehrotra), Harvard Medical School, Boston, Mass
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23
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Kukafka R, Eysenbach G, Burns S, Doan TT, Schweiberger KA, Yabes JG, Hanmer J, Krishnamurti T. Parent-Reported Use of Pediatric Primary Care Telemedicine: Survey Study. J Med Internet Res 2023; 25:e42892. [PMID: 36757763 PMCID: PMC9951070 DOI: 10.2196/42892] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2022] [Revised: 11/18/2022] [Accepted: 01/19/2023] [Indexed: 01/20/2023] Open
Abstract
BACKGROUND Telemedicine delivered from primary care practices became widely available for children during the COVID-19 pandemic. OBJECTIVE Focusing on children with a usual source of care, we aimed to examine factors associated with use of primary care telemedicine. METHODS In February 2022, we surveyed parents of children aged ≤17 years on the AmeriSpeak panel, a probability-based panel of representative US households, about their children's telemedicine use. We first compared sociodemographic factors among respondents who did and did not report a usual source of care for their children. Among those reporting a usual source of care, we used Rao-Scott F tests to examine factors associated with parent-reported use versus nonuse of primary care telemedicine for their children. RESULTS Of 1206 respondents, 1054 reported a usual source of care for their children. Of these respondents, 301 of 1054 (weighted percentage 28%) reported primary care telemedicine visits for their children. Factors associated with primary care telemedicine use versus nonuse included having a child with a chronic medical condition (87/301, weighted percentage 27% vs 113/753, 15%, respectively; P=.002), metropolitan residence (262/301, weighted percentage 88% vs 598/753, 78%, respectively; P=.004), greater internet connectivity concerns (60/301, weighted percentage 24% vs 116/753, 16%, respectively; P=.05), and greater health literacy (285/301, weighted percentage 96% vs 693/753, 91%, respectively; P=.005). CONCLUSIONS In a national sample of respondents with a usual source of care for their children, approximately one-quarter reported use of primary care telemedicine for their children as of 2022. Equitable access to primary care telemedicine may be enhanced by promoting access to primary care, sustaining payment for primary care telemedicine, addressing barriers in nonmetropolitan practices, and designing for lower health-literacy populations.
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Affiliation(s)
| | | | - Sarah Burns
- Department of Pediatrics, University of Pittsburgh, Pittsburgh, PA, United States
| | - Tran T Doan
- Department of Pediatrics, University of Pittsburgh, Pittsburgh, PA, United States
| | | | - Jonathan G Yabes
- Department of Medicine, University of Pittsburgh, Pittsburgh, PA, United States
| | - Janel Hanmer
- Department of Medicine, University of Pittsburgh, Pittsburgh, PA, United States
| | - Tamar Krishnamurti
- Department of Medicine, University of Pittsburgh, Pittsburgh, PA, United States
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24
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Malley BE, Yabes JG, Gimbel E, Chang CCH, Yealy DM, Fine MJ, Angus DC, Huang DT. Impact of adherence to procalcitonin antibiotic prescribing guideline recommendations for low procalcitonin levels on antibiotic use. BMC Infect Dis 2023; 23:30. [PMID: 36658543 PMCID: PMC9850552 DOI: 10.1186/s12879-022-07923-0] [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] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2022] [Accepted: 12/05/2022] [Indexed: 01/20/2023] Open
Abstract
BACKGROUND The Procalcitonin Antibiotic Consensus Trial (ProACT) found provision of a procalcitonin antibiotic prescribing guideline to hospital-based clinicians did not reduce antibiotic use. Possible reasons include clinician reluctance to follow the guideline, with an observed 64.8% adherence rate. In this study we sought to determine the threshold adherence rate for reduction in antibiotic use, and to explore opportunities to increase adherence. METHODS This study is a retrospective analysis of ProACT data. ProACT randomized 1656 patients presenting to 14 U.S. hospitals with suspected lower respiratory tract infection to usual care or provision of procalcitonin assay results and an antibiotic prescribing guideline to the treating clinicians. We simulated varying adherence to guideline recommendations for low procalcitonin levels and determined which threshold adherence rate could have resulted in rejection of the null hypothesis of no difference between groups at alpha = 0.05. We also performed sensitivity analyses within specific clinical settings and grouped patients initially prescribed antibiotics despite low procalcitonin into low, medium, and high risk of illness severity or bacterial infection. RESULTS Our primary outcome was number of antibiotic-days by day 30 using an intention-to-treat approach and a null hypothesis of no difference in antibiotic use. We determined that an 84% adherence rate in the hospital setting (emergency department and inpatient) for low procalcitonin could have allowed rejection of the null hypothesis (3.7 vs 4.3 antibiotic-days, p = 0.048). The threshold adherence rate was 76% for continued guideline adherence after discharge. Even 100% adherence in the emergency department alone failed to reduce antibiotic-days. Of the 218 patients prescribed antibiotics in the emergency department despite low procalcitonin, 153 (70.2%) were categorized as low or medium risk. CONCLUSIONS High adherence in the hospital setting to a procalcitonin antibiotic prescribing guideline is necessary to reduce antibiotic use in suspected lower respiratory tract infection. Continued guideline adherence after discharge and withholding of antibiotics in low and medium risk patients with low procalcitonin may offer impactful potential opportunities for antibiotic reduction. Trial registration Procalcitonin Antibiotic Consensus Trial (ProACT), ClinicalTrials.gov Identifier: NCT02130986. First posted May 6, 2014.
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Affiliation(s)
- Brian E. Malley
- grid.21925.3d0000 0004 1936 9000The CRISMA (Clinical Research, Investigation, and Systems Modeling of Acute Illness) Center, University of Pittsburgh, Pittsburgh, PA USA ,grid.21925.3d0000 0004 1936 9000Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA USA
| | - Jonathan G. Yabes
- grid.21925.3d0000 0004 1936 9000Division of General Internal Medicine, University of Pittsburgh, Pittsburgh, PA USA
| | - Elizabeth Gimbel
- grid.21925.3d0000 0004 1936 9000Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA USA
| | - Chung-Chou H. Chang
- grid.21925.3d0000 0004 1936 9000Division of General Internal Medicine, University of Pittsburgh, Pittsburgh, PA USA
| | - Donald M. Yealy
- grid.21925.3d0000 0004 1936 9000Department of Emergency Medicine, University of Pittsburgh, Pittsburgh, PA USA
| | - Michael J. Fine
- grid.413935.90000 0004 0420 3665Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA USA
| | - Derek C. Angus
- grid.21925.3d0000 0004 1936 9000The CRISMA (Clinical Research, Investigation, and Systems Modeling of Acute Illness) Center, University of Pittsburgh, Pittsburgh, PA USA ,grid.21925.3d0000 0004 1936 9000Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA USA ,grid.21925.3d0000 0004 1936 9000The MACRO (Multidisciplinary Acute Care Research Organization) Center, University of Pittsburgh, Pittsburgh, PA USA
| | - David T. Huang
- grid.21925.3d0000 0004 1936 9000The CRISMA (Clinical Research, Investigation, and Systems Modeling of Acute Illness) Center, University of Pittsburgh, Pittsburgh, PA USA ,grid.21925.3d0000 0004 1936 9000Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA USA ,grid.21925.3d0000 0004 1936 9000Department of Emergency Medicine, University of Pittsburgh, Pittsburgh, PA USA ,grid.21925.3d0000 0004 1936 9000The MACRO (Multidisciplinary Acute Care Research Organization) Center, University of Pittsburgh, Pittsburgh, PA USA ,grid.21925.3d0000 0004 1936 9000University of Pittsburgh, 606B Scaife Hall, 3550 Terrace Street, Pittsburgh, PA 15261 USA
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Gul ZG, Sharbaugh DR, Guercio CJ, Pelzman DL, Jones CA, Hacker EC, Anyaeche VI, Bowers L, Shah AM, Stencel MG, Yabes JG, Jacobs BL, Davies BJ. Large Variations in the Prices of Urologic Procedures at Academic Medical Centers 1 Year After Implementation of the Price Transparency Final Rule. JAMA Netw Open 2023; 6:e2249581. [PMID: 36602800 PMCID: PMC9857154 DOI: 10.1001/jamanetworkopen.2022.49581] [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] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2022] [Accepted: 11/09/2022] [Indexed: 01/06/2023] Open
Abstract
Importance Patients with urologic diseases often experience financial toxicity, defined as high levels of financial burden and concern, after receiving care. The Price Transparency Final Rule, which requires hospitals to disclose both the commercial and cash prices for at least 300 services, was implemented to facilitate price shopping, decrease price dispersion, and lower health care costs. Objective To evaluate compliance with the Price Transparency Final Rule and to quantify variations in the price of urologic procedures among academic hospitals and by insurance class. Design, Setting, and Participants This was a cross-sectional study that determined the prices of 5 common urologic procedures among academic medical centers and by insurance class. Prices were obtained from the Turquoise Health Database on March 24, 2022. Academic hospitals were identified from the Association of American Medical Colleges website. The 5 most common urologic procedures were cystourethroscopy, prostate biopsy, laparoscopic radical prostatectomy, transurethral resection of the prostate, and ureteroscopy with laser lithotripsy. Using the corresponding Current Procedural Terminology codes, the Turquoise Health Database was queried to identify the cash price, Medicare price, Medicaid price, and commercial insurance price for these procedures. Exposures The Price Transparency Final Rule, which went into effect January 1, 2021. Main Outcomes and Measures Variability in procedure price among academic medical centers and by insurance class (Medicare, Medicaid, commercial, and cash price). Results Of 153 hospitals, only 20 (13%) listed a commercial price for all 5 procedures. The commercial price was reported most often for cystourethroscopy (86 hospitals [56%]) and least often for laparoscopic radical prostatectomy (45 hospitals [29%]). The cash price was lower than the Medicare, Medicaid, and commercial price at 24 hospitals (16%). Prices varied substantially across hospitals for all 5 procedures. There were significant variations in the prices of cystoscopy (χ23 = 85.9; P = .001), prostate biopsy (χ23 = 64.6; P = .001), prostatectomy (χ23 = 24.4; P = .001), transurethral resection of the prostate (χ23 = 51.3; P = .001), and ureteroscopy with laser lithotripsy (χ23 = 63.0; P = .001) by insurance type. Conclusions and Relevance These findings suggest that, more than 1 year after the implementation of the Price Transparency Final Rule, there are still large variations in the prices of urologic procedures among academic hospitals and by insurance class. Currently, in certain situations, health care costs could be reduced if patients paid out of pocket. The Centers for Medicare & Medicaid Services may improve price transparency by better enforcing penalties for noncompliance, increasing penalties, and ensuring that hospitals report prices in a way that is easy for patients to access and understand.
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Affiliation(s)
- Zeynep G. Gul
- Division of Urology, University of Washington in St Louis, St Louis, Missouri
| | - Danielle R. Sharbaugh
- Department of Urology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Cailey J. Guercio
- Department of Urology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Daniel L. Pelzman
- Department of Urology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Cameron A. Jones
- Department of Urology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Emily C. Hacker
- University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | | | - Levi Bowers
- University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Ashti M. Shah
- University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Michael G. Stencel
- Department of Urology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Jonathan G. Yabes
- Department of Medicine, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Bruce L. Jacobs
- Department of Urology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Benjamin J. Davies
- Department of Urology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
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Wittman SR, Yabes JG, Sabik LM, Kahn JM, Ray KN. Patient and Family Factors Associated with Use of Telemedicine Visits for Pediatric Acute Respiratory Tract Infections, 2018-2019. Telemed J E Health 2023; 29:127-136. [PMID: 35639360 PMCID: PMC9918348 DOI: 10.1089/tmj.2022.0097] [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: 02/28/2022] [Revised: 04/18/2022] [Accepted: 04/20/2022] [Indexed: 01/12/2023] Open
Abstract
Background: Pediatric acute respiratory tract infections (ARTIs) were a common reason for commercial direct-to-consumer (DTC) telemedicine use before the COVID-19 pandemic, but the factors associated with this use are unknown. Objective: To identify child and family factors associated with use of commercial DTC telemedicine for ARTIs in 2018-2019. Methods: We performed a retrospective cohort analysis of claims data from the Optum Clinformatics® Data Mart Database. Among children with ARTI visits, we fitted logit models to examine child and family characteristics associated with DTC telemedicine use. Results: Of 660,725 children with ARTI visits, 12,944 (2.0%) had ≥1 commercial DTC telemedicine encounter. The odds of DTC telemedicine use were higher for children with age ≥12 years, lower parent educational attainment, higher household income, white non-Hispanic race/ethnicity, and residency in the West South Central census division. Conclusion: In 2018-2019, commercial DTC telemedicine use varied with child age, child race/ethnicity parent educational attainment, household income, and geography.
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Affiliation(s)
- Samuel R. Wittman
- Department of Pediatrics, University of Pittsburgh School of Medicine, UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Jonathan G. Yabes
- Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Lindsay M. Sabik
- Department of Health Policy and Management, University of Pittsburgh Graduate School of Public Health, Pittsburgh, Pennsylvania, USA
| | - Jeremy M. Kahn
- Department of Health Policy and Management, University of Pittsburgh Graduate School of Public Health, Pittsburgh, Pennsylvania, USA
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Kristin N. Ray
- Department of Pediatrics, University of Pittsburgh School of Medicine, UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania, USA
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Zupa MF, Perez S, Palmisano G, Kieffer EC, Piatt GA, Valbuena FM, Deverts DJ, Yabes JG, Heisler M, Rosland AM. Changes in Self-management During the COVID-19 Pandemic Among Adults with Type 2 Diabetes at a Federally Qualified Health Center. J Immigr Minor Health 2022; 24:1375-1378. [PMID: 35301642 PMCID: PMC8929472 DOI: 10.1007/s10903-022-01351-7] [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] [Accepted: 03/05/2022] [Indexed: 11/27/2022]
Abstract
The COVID-19 pandemic affected how adults with diabetes perform self-management, and impacts may be greater among vulnerable populations. We assessed the impact of the pandemic on diabetes self-management among adults with type 2 diabetes at a Federally Qualified Health Center. Participants were surveyed by phone in Spanish and English from July to October of 2020. Most respondents (74%) were Latino and preferred to speak Spanish, with mean age of 54 years and mean HbA1c of 9.2%. Fifty-three percent reported less physical activity during the pandemic. While 43% had more difficulty obtaining healthy food, 38% reported eating more healthfully. Sixty-one percent had increased difficulty accessing medical care. Many felt more socially isolated (49%) and stressed (51%). Changes in diabetes self-management were both positive and negative for majority Latino patients in this low-resource community, which may require tailored approaches to mitigate negative impacts of the pandemic on physical and mental health.
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Affiliation(s)
- Margaret F Zupa
- Division of Endocrinology and Metabolism, University of Pittsburgh School of Medicine, 3601 Fifth Ave, Suite 3A, 200 Lothrop Street, Pittsburgh, PA, 15213, USA.
| | - Stephanie Perez
- Community Health and Social Services Center, Inc, 5635 West Fort Street, Detroit, MI, 48209, USA
| | - Gloria Palmisano
- Community Health and Social Services Center, Inc, 5635 West Fort Street, Detroit, MI, 48209, USA
| | - Edith C Kieffer
- University of Michigan School of Social Work, 1080 South University Avenue, Ann Arbor, MI, 48109, USA
| | - Gretchen A Piatt
- University of Michigan School of Medicine, 1301 Catherine St., Ann Arbor, MI, 48109, USA
- University of Michigan School of Public Health, 1415 Washington Heights, Ann Arbor, MI, 48109, USA
| | - Felix M Valbuena
- Community Health and Social Services Center, Inc, 5635 West Fort Street, Detroit, MI, 48209, USA
| | - Denise J Deverts
- Division of General Internal Medicine, University of Pittsburgh School of Medicine, 230 McKee Place, Suite 600, Pittsburgh, PA, 15213, USA
| | - Jonathan G Yabes
- Division of General Internal Medicine, University of Pittsburgh School of Medicine, 230 McKee Place, Suite 600, Pittsburgh, PA, 15213, USA
| | - Michele Heisler
- University of Michigan School of Medicine, 1301 Catherine St., Ann Arbor, MI, 48109, USA
- University of Michigan School of Public Health, 1415 Washington Heights, Ann Arbor, MI, 48109, USA
- VA Ann Arbor Center for Clinical Management Research, 2215 Fuller Rd, Ann Arbor, MI, 48105, USA
| | - Ann-Marie Rosland
- Division of General Internal Medicine, University of Pittsburgh School of Medicine, 230 McKee Place, Suite 600, Pittsburgh, PA, 15213, USA
- VA Pittsburgh Center for Health Equity Research and Promotion, 4100 Allequippa St, Pittsburgh, PA, 15240, USA
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28
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Jones CA, Pekala KR, Armann KM, Maganty A, Yabes JG, Bandari J, Yu M, Davies BJ, Jacobs BL. Opioid-Free Ureteroscopy: Are Academic Urologists Lagging Behind Private Practice? Urology 2022; 167:56-60. [PMID: 35780945 DOI: 10.1016/j.urology.2022.06.021] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2022] [Revised: 05/11/2022] [Accepted: 06/05/2022] [Indexed: 01/12/2023]
Abstract
OBJECTIVE To examine overall trends in opioid prescribing after ureteroscopy and compared opioid use between private and academic practice settings. We also analyzed the potential for spillover effect from an unrelated opioid-reduction initiative for major oncologic surgery. METHODS We conducted a retrospective chart review of all ureteroscopies performed within our system at four distinct time points from 2016-2019. We recorded the type and number of opioid pills prescribed and calculated oral morphine equivalents. Analysis included comparison between community and academic hospitals as well as pre- and post-initiative. RESULTS 555 patients undergoing ureteroscopy and 29 attending surgeons were included in the analysis. The median prescription size per ureteroscopy decreased throughout the study period in both the private and academic settings. From 2016-2017, median oral morphine equivalents (OMEs) decreased from 60 to 0 in the private setting and remained at 0 for the duration of the study period. Opioid reduction in the academic setting lagged behind private practitioners but median OMEs did steadily decrease to 0 in 2019. No significant spillover effect was observed. CONCLUSION Since 2016, opioid prescribing following ureteroscopy has decreased in both the private and academic practice settings. Notably, private practice urologists achieved a median of 0 opioids 2 years prior to academic urologists. These data suggest that, in some circumstances, academic institutions may have been slower to respond to the opioid epidemic.
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Affiliation(s)
| | | | - Kody M Armann
- University of Pittsburgh School of Medicine, Pittsburgh, PA
| | | | - Jonathan G Yabes
- Center for Research on Health Care, Pittsburgh, PA; UPMC Division of General Internal Medicine, Pittsburgh, PA
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29
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Myrga JM, Wu S, Gul ZG, Yu M, Sharbaugh DR, Mihalo J, Patnaik S, Vasan RV, Miller DT, Pere MP, Yabes JG, Jacobs BL, Davies BJ. Discharge Opioids are Unnecessary Following Radical Cystectomy. Urology 2022; 170:91-95. [PMID: 36055420 DOI: 10.1016/j.urology.2022.08.025] [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] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2022] [Revised: 08/16/2022] [Accepted: 08/18/2022] [Indexed: 11/19/2022]
Abstract
OBJECTIVE To show that zero-opioid discharges after both open and robotic cystectomy are feasible and to examine the impact of zero-opioid discharges on patient interaction with the physician's office. MATERIALS AND METHODS 107 patients who underwent either open or robotic radical cystectomy from March 1, 2020 to December 30, 2020 were identified. Patient demographics, perioperative data, and 30 day pain related outcomes including phone calls, office visits, requests for pain medication, emergency department visits, and readmissions were abstracted from the chart. We then examined variables associated with a zero-opioid discharge. RESULTS Thirty-two patients were discharged with an opioid prescription (Median Oral Morphine Equivalents Prescribed = 90) and seventy-five were discharged without an opioid prescription. On regression analysis, age (OR 1.07, 95% CI [1.02-1.12]) and pathology (OR 0.36, 95% CI[0.14-0.9]) remained significantly associated with postoperative opioid prescriptions. There were no differences in the percent of patients presenting to the emergency department, being readmitted, calling the office, calling the office regarding pain, or requesting opioid prescriptions within thirty days of discharge, or the number of post-operative office visits (p> 0.05 for all). CONCLUSIONS Patients can safely be discharged home without opioids following cystectomy, regardless of robotic or open approach. Age and pathology are predictors of the need for an opioid prescription on discharge. These patients did not have increased follow-up visits, phone calls, or requests for pain medication.
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Affiliation(s)
- J M Myrga
- University of Pittsburgh School of Medicine, Department of Urology, Pittsburgh, PA.
| | - S Wu
- University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Z G Gul
- University of Pittsburgh School of Medicine, Department of Urology, Pittsburgh, PA
| | - M Yu
- University of Pittsburgh School of Medicine, Department of Urology, Pittsburgh, PA
| | - D R Sharbaugh
- University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - J Mihalo
- University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - S Patnaik
- University of Pittsburgh School of Medicine, Department of Urology, Pittsburgh, PA
| | - R V Vasan
- University of Pittsburgh School of Medicine, Department of Urology, Pittsburgh, PA
| | - D T Miller
- University of Pittsburgh School of Medicine, Department of Urology, Pittsburgh, PA
| | - M P Pere
- University of Pittsburgh School of Medicine, Department of Urology, Pittsburgh, PA
| | - J G Yabes
- Division of Internal Medicine, Department of Medicine, University of Pittsburgh, Pittsburgh, PA; Center for Research on Health Care, Department of Medicine, University of Pittsburgh, Pittsburgh, PA
| | - B L Jacobs
- University of Pittsburgh School of Medicine, Department of Urology, Pittsburgh, PA
| | - B J Davies
- University of Pittsburgh School of Medicine, Department of Urology, Pittsburgh, PA
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Yang X, Jeong K, Yabes JG, Ragni MV. Prevalence and risk factors for hepatocellular carcinoma in individuals with haemophilia in the era of direct-acting antiviral agents: A national inpatient sample study. Haemophilia 2022; 28:769-775. [PMID: 35727998 DOI: 10.1111/hae.14607] [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] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2022] [Revised: 05/08/2022] [Accepted: 06/01/2022] [Indexed: 12/17/2022]
Abstract
BACKGROUND Hepatocellular carcinoma (HCC) is a major complication of chronic hepatitis C virus (HCV) infection. Among haemophilic (H) men, HCV is the leading cause of liver disease. Direct-acting antiviral agents (DAA) reduce HCV viral load, but impact on HCC is unknown. METHODS This was a retrospective study of adult H and nonhaemophilic (NH) male discharges, with and without HCC, identified by ICD-10 codes in the National Inpatient Sample (NIS) database, 2016-2018, with DAA availability. Analyses included discharge-level weights to reflect national estimates. Categorical variables were assessed by Rao-Scott chi-square and continuous variables by weighted simple linear regression. HCC correlates were determined by weighted multivariable logistic regression. RESULTS Among 7,674,969 adult male discharges, 3730 H (.04%) were identified in 2016-2018, of whom 10.06% had HCV and 1.07% had HCC, significantly higher than NH (1.22% and .27%, respectively) all P < .001. Annual HCC rates were similar during the 3-year period (2016-2018) in H and NH. Among H, HCC is associated with older age and higher rates of HCV, HBV, NASH, end-stage liver disease, and Charlson comorbidity (CCI), each P < .001. Among HCC, H were younger and more likely HIV+, each P < .001, but less likely alcoholic (P = .018) or hyperlipidaemic (P = .008) compared to NH. In multivariable regression, risk factors for HCC among H included NASH (OR 21.6), HCV (OR 3.96), CCI (OR1.54), all P < .001, while HIV and hyperlipidaemia were protective. CONCLUSION From 2016 to 2018, HCC rates did not change significantly in haemophilia discharges. NASH, HCV, and CCI are significant risks for HCC in haemophilia during the DAA-era.
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Affiliation(s)
- Xi Yang
- University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA.,Hemophilia Center of Western Pennsylvania, Pittsburgh, Pennsylvania, USA
| | - Kwonho Jeong
- Center for Research on Health Care Data Center, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Jonathan G Yabes
- Center for Research on Health Care Data Center, University of Pittsburgh, Pittsburgh, Pennsylvania, USA.,Division of General Internal Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA.,Department of Biostatistics, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Margaret V Ragni
- University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA.,Hemophilia Center of Western Pennsylvania, Pittsburgh, Pennsylvania, USA
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Pekala KR, Yabes JG, Bandari J, Yu M, Davies BJ, Sabik LM, Kahn JM, Jacobs BL. Corrigendum to ‘The centralization of bladder cancer care and its implications for patient travel distance’ [Urologic Oncology: Seminars and Original Investigations volume 39 (2021) 834.e.9–834.e.20/9680]. Urol Oncol 2022; 40:203-206. [DOI: 10.1016/j.urolonc.2021.12.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Abstract
Rationale & Objective In patients with chronic kidney disease (CKD), self-rated health ("In general, how do you rate your health?") is associated with mortality. The association of self-rated health with functional status is unknown. We evaluated the association of limitations in activities of daily living (ADLs) with self-rated health and clinical correlates in a cohort of patients with CKD stages 1-5. Study Design Prospective cohort study. Setting & Participants Patients with CKD at a nephrology outpatient clinic in western Pennsylvania. Outcome Patients participated in a survey assessing their self-rated health (5-point Likert scale) and physical (ambulation, dressing, shopping) and cognitive (executive and memory) ADLs. Adjusted analysis was performed using logistic regression models. Analytical Approach Logistic regression was conducted to examine the adjusted association of 3 dependent variables (sum of total, physical, and cognitive ADL limitations) with self-rated health (independent variable of interest). Results The survey was completed by 1,268 participants (mean age, 60 years; 49% females, and 74% CKD stages 3-5), of which 41% reported poor-to-fair health. Overall, 35.9% had at least 1 physical ADL limitation, 22.1% had at least 1 cognitive ADL limitation, and 12.5% had at least 3 ADL limitations. Ambulation was the most frequently reported limitation and was more common in patients reporting poor-to-fair self-rated health compared with those with good-to-excellent self-rated health (58.1% vs 17.4%, P < 0.001). In our fully adjusted model, poor-to-fair self-rated health was strongly associated with limitations in at least 3 ADLs (total ADL) [OR 8.29 (95% CI, 5.23-13.12)]. There was no significant association of eGFR with ADL limitations. Limitations Selection bias due to optional survey completion, residual confounding, and use of abbreviated (as opposed to full) ADL questionnaires. Conclusions Poor-to-fair self-rated health is strongly associated with physical ADL limitations in patients with CKD. Future studies should evaluate whether self-rated health questions may be useful for identifying patients who can benefit from additional evaluation and treatment of functional limitations to improve patient-centered outcomes.
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Affiliation(s)
- Jacqueline Lee
- Department of Medicine, School of Medicine, Pittsburgh, PA
| | - Khaled Abdel-Kader
- Vanderbilt University, Nephrology and Hypertension Division, Nashville, TN
| | - Jonathan G Yabes
- Center for Research on Health Care, Division of General Internal Medicine, Pittsburgh, PA
| | - Manqi Cai
- Department of Biostatistics, University of Pittsburgh, Pittsburgh, PA
| | - Hsin-Hsiung Chang
- Division of Nephrology, Department of Internal Medicine, Changhua Christian Hospital, Changhua, Taiwan
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Barbash IJ, Davis BS, Yabes JG, Seymour CW, Angus DC, Kahn JM. Treatment Patterns and Clinical Outcomes After the Introduction of the Medicare Sepsis Performance Measure (SEP-1). Ann Intern Med 2021; 174:927-935. [PMID: 33872042 PMCID: PMC8844885 DOI: 10.7326/m20-5043] [Citation(s) in RCA: 28] [Impact Index Per Article: 9.3] [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] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Medicare requires that hospitals report on their adherence to the Severe Sepsis and Septic Shock Early Management Bundle (SEP-1). OBJECTIVE To evaluate the effect of SEP-1 on treatment patterns and patient outcomes. DESIGN Longitudinal study of hospitals using repeated cross-sectional cohorts of patients. SETTING 11 hospitals within an integrated health system. PATIENTS 54 225 encounters between January 2013 and December 2017 for adults with sepsis who were hospitalized through the emergency department. INTERVENTION Onset of the SEP-1 reporting requirement in October 2015. MEASUREMENTS Changes in SEP-1-targeted processes, including antibiotic administration, lactate measurement, and fluid administration at 3 hours from sepsis onset; repeated lactate and vasopressor administration for hypotension within 6 hours of sepsis onset; and sepsis outcomes, including risk-adjusted intensive care unit (ICU) admission, in-hospital mortality, and home discharge among survivors. RESULTS Two years after its implementation, SEP-1 was associated with variable changes in process measures, with the greatest effect being an increase in lactate measurement within 3 hours of sepsis onset (absolute increase, 23.7 percentage points [95% CI, 20.7 to 26.7 percentage points]; P < 0.001). There were small increases in antibiotic administration (absolute increase, 4.7 percentage points [CI, 1.9 to 7.6 percentage points]; P = 0.001) and fluid administration of 30 mL/kg of body weight within 3 hours of sepsis onset (absolute increase, 3.4 percentage points [CI, 1.5 to 5.2 percentage points]; P < 0.001). There was no change in vasopressor administration. There was a small increase in ICU admissions (absolute increase, 2.0 percentage points [CI, 0 to 4.0 percentage points]; P = 0.055) and no changes in mortality (absolute change, 0.1 percentage points [CI, -0.9 to 1.1 percentage points]; P = 0.87) or discharge to home. LIMITATION Data are from a single health system. CONCLUSION Implementation of the SEP-1 mandatory reporting program was associated with variable changes in process measures, without improvements in clinical outcomes. Revising the measure may optimize its future effect. PRIMARY FUNDING SOURCE Agency for Healthcare Research and Quality.
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Affiliation(s)
- Ian J Barbash
- University of Pittsburgh School of Medicine and UPMC Health System, Pittsburgh, Pennsylvania (I.J.B., C.W.S.)
| | - Billie S Davis
- University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania (B.S.D., J.G.Y.)
| | - Jonathan G Yabes
- University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania (B.S.D., J.G.Y.)
| | - Chris W Seymour
- University of Pittsburgh School of Medicine and UPMC Health System, Pittsburgh, Pennsylvania (I.J.B., C.W.S.)
| | - Derek C Angus
- University of Pittsburgh School of Medicine, University of Pittsburgh Graduate School of Public Health, and UPMC Health System, Pittsburgh, Pennsylvania (D.C.A., J.M.K.)
| | - Jeremy M Kahn
- University of Pittsburgh School of Medicine, University of Pittsburgh Graduate School of Public Health, and UPMC Health System, Pittsburgh, Pennsylvania (D.C.A., J.M.K.)
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Pekala KR, Yabes JG, Bandari J, Yu M, Davies BJ, Sabik LM, Kahn JM, Jacobs BL. The centralization of bladder cancer care and its implications for patient travel distance. Urol Oncol 2021; 39:834.e9-834.e20. [PMID: 34162498 DOI: 10.1016/j.urolonc.2021.04.030] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2021] [Revised: 04/16/2021] [Accepted: 04/23/2021] [Indexed: 10/21/2022]
Abstract
OBJECTIVES To evaluate the impact of centralized surgical and nonsurgical care (i.e., radiation and chemotherapy) on travel distances and survival outcomes for patients with advanced bladder cancer. Bladder cancer is a disease with high mortality for which treatment access is paramount and survival is superior in patients receiving surgery at high-volume centers. METHODS Using SEER-Medicare, we identified patients 66 years or older diagnosed with bladder cancer between 2004-2013. We categorized patients as treated with either surgical (i.e., radical cystectomy) or nonsurgical (i.e., radiation or chemotherapy) care. We fit a linear probability model to generate the predicted proportion of patients treated at the top quintile of volume over time and assessed travel distance, 1-year all-cause mortality, and 1-year bladder cancer-specific mortality over time. RESULTS A total of 6,756 and 10,383 patients underwent surgical and nonsurgical care, respectively. The percentage of patients treated at high-volume centers increased over the study period for both surgical care (53% to 62%) and nonsurgical care (47% to 55%), (both P< 0.001). Median travel distance increased (11.8 to 20.3 miles) for surgical care and (6.5 to 8.3 miles) for nonsurgical care, (both P < 0.001). The 1-year adjusted all-cause mortality and 1-year adjusted bladder-cancer specific mortality decreased significantly for both surgical and nonsurgical care (both P < 0.05). CONCLUSIONS Over time, centralization of surgical and nonsurgical care for bladder cancer patients increased, which was associated with increasing patient travel distance and decreased all-cause and bladder-cancer specific mortality.
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Affiliation(s)
| | - Jonathan G Yabes
- Center for Research on Health Care; Division of General Internal Medicine, Department of Medicine
| | | | | | | | - Lindsay M Sabik
- Center for Research on Health Care; Department of Health Policy and Management, Graduate School of Public Health
| | - Jeremy M Kahn
- Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA
| | - Bruce L Jacobs
- Department of Urology; Center for Research on Health Care
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Maganty A, Yu M, Anyaeche VI, Zhu T, Hay JM, Davies BJ, Yabes JG, Jacobs BL. Referral pattern for urologic malignancies before and during the COVID-19 pandemic. Urol Oncol 2021; 39:268-276. [PMID: 33308974 PMCID: PMC7722486 DOI: 10.1016/j.urolonc.2020.11.027] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2020] [Revised: 10/29/2020] [Accepted: 11/16/2020] [Indexed: 12/13/2022]
Abstract
INTRODUCTION The COVID-19 pandemic has required significant restructuring of healthcare with conservation of resources and maintaining social distancing standards. With these new initiatives, it is conceivable that the diagnosis of cancer care may be delayed. We aimed to evaluate differences in patient populations being evaluated for cancer before and during the COVID-19 pandemic. METHODS AND MATERIALS We performed a retrospective review of our electronic medical record and examined patient characteristics of those presenting for a possible new cancer diagnosis to our urologic oncology clinic. Data was analyzed using logistic and linear regression models. RESULTS During the 3-month period before the COVID-19 pandemic began, 585 new patients were seen in one urologic oncology practice. The following 3-month period, during the COVID-19 pandemic, 362 patients were seen, corresponding to a 38% decline. Visits per week increased to pre-COVID-19 levels for kidney and bladder cancer as the county entered the green phase. Prostate cancer visits per week remained below pre-COVID-19 levels in the green phase. When the 2 populations pre-COVID-19 and COVID-19 were compared, there were no notable differences on regression analysis. CONCLUSION The COVID-19 pandemic decreased the total volume of new patient referrals for possible genitourinary cancer diagnoses. The impact this will have on cancer survival remains to be determined.
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Affiliation(s)
- Avinash Maganty
- Department of Urology, University of Pittsburgh Medical Center, Pittsburgh, PA,Corresponding author. Tel.: 480-292-0661
| | - Michelle Yu
- Department of Urology, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Vivian I. Anyaeche
- School of Medicine, University of Pittsburgh, Pittsburgh Medical Center, Pittsburgh, PA
| | - Toby Zhu
- School of Medicine, University of Pittsburgh, Pittsburgh Medical Center, Pittsburgh, PA
| | - Jordan M. Hay
- School of Medicine, University of Pittsburgh, Pittsburgh Medical Center, Pittsburgh, PA
| | - Benjamin J. Davies
- Department of Urology, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Jonathan G. Yabes
- Division of Internal Medicine, Department of Medicine, University of Pittsburgh, Pittsburgh, PA,Center for Research on Health Care, Department of Medicine, University of Pittsburgh, Pittsburgh, PA
| | - Bruce L. Jacobs
- Department of Urology, University of Pittsburgh Medical Center, Pittsburgh, PA
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Seaman CD, Yabes JG, Lalama CM, Ragni MV. Factor VIII concentrate dosing with lean body mass, ideal body weight and total body weight in overweight and obesity: A randomized, controlled, open-label, 3 × 3 crossover trial. Haemophilia 2021; 27:351-357. [PMID: 33749970 DOI: 10.1111/hae.14285] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2020] [Revised: 01/21/2021] [Accepted: 02/15/2021] [Indexed: 01/19/2023]
Abstract
INTRODUCTION Obesity alters the pharmacokinetic (PK) properties of drugs making it difficult to determine the appropriate dose when administering weight-based medications. Alternative descriptors of body weight, such as lean body mass (LBM) and ideal body weight (IBW), are sometimes used in these situations. METHODS We performed a single-centre, randomized, controlled, open-label, 3 × 3 crossover trial to determine whether recombinant factor VIII (rFVIII) dosing based on LBM and IBW achieves a targeted FVIII recovery with better precision than based on total body weight (TBW) in overweight and obese, adult males with haemophilia A. Participants were randomized to 1 of 6 possible FVIII concentrate dosing sequence scenarios (TBW, LBM and IBW). Recombinant FVIII was administered on 3 separate weeks following a washout period of at least 72 hours. RESULTS A total of 19 participants were randomized and completed the study. FVIII recovery was lower at 30 minutes post-rFVIII infusion in LBM vs TBW and IBW vs TBW-based dosing, mean difference -0.38 (95% CI: -0.56, -0.20) and -0.28 (95% CI: -0.47, -0.10) IU/dL per IU/kg, respectively. In LBM vs TBW and IBW vs TBW-based dosing, there was a non-significant increase in the proportion of participants with a targeted FVIII recovery of 2.00 ± 0.20 IU/dl per IU/kg, OR = 1.93 (95% CI: 0.44, 8.55) and OR = 3.65 (0.80, 16.72), respectively. DISCUSSION Based on our study's findings, overweight and obese patients with haemophilia A may benefit from an individualized PK analysis using LBM and IBW to determine the most accurate, and potentially cost-effective, method of achieving targeted FVIII recovery.
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Affiliation(s)
- Craig D Seaman
- Department of Medicine, Division of Hematology/Oncology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA.,Hemophilia Center of Western Pennsylvania, Pittsburgh, PA, USA
| | - Jonathan G Yabes
- Center for Research on Health Care Data Center, University of Pittsburgh, Pittsburgh, PA, USA
| | - Christina M Lalama
- Center for Research on Health Care Data Center, University of Pittsburgh, Pittsburgh, PA, USA
| | - Margaret V Ragni
- Department of Medicine, Division of Hematology/Oncology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA.,Hemophilia Center of Western Pennsylvania, Pittsburgh, PA, USA
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Hugar LA, Yabes JG, Filippou P, Wulff-Burchfield EM, Lopa SH, Gore J, Davies BJ, Jacobs BL. High-intensity end-of-life care among Medicare beneficiaries with bladder cancer. Urol Oncol 2021; 39:731.e17-731.e24. [PMID: 33676849 DOI: 10.1016/j.urolonc.2021.02.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2020] [Revised: 01/27/2021] [Accepted: 02/04/2021] [Indexed: 11/25/2022]
Abstract
OBJECTIVES To quantify the proportion of patients receiving high-intensity end-of-life care, identify associated risk factors, and assess how receipt of palliative care impact end-of-life care; as the delivery of such care, and how it relates to palliative care, has not been reported in bladder cancer SUBJECTS AND METHODS: We conducted a retrospective cohort study of patients with bladder cancer who died within 1 year of diagnosis using Surveillance, Epidemiology, and End Results linked Medicare data. The primary outcome was a composite measure of high-intensity end-of-life care (>1 hospital admission, >1 ED visit, or ≥1 ICU admission within the last month of life; receipt of chemotherapy within the last 2 weeks of life; or acute care in-hospital death). Secondary outcomes included the use of such care over time and any association with the use of palliative care. A generalized linear mixed model assessed for independent determinants. RESULTS Overall, 45% of patients received high-intensity end-of-life care. This proportion decreased over time. Patients receiving high-intensity care had higher rates of comorbidities, advanced bladder cancer, and nonbladder cancer cause of death. These patients more often received palliative care but, compared to those not receiving high-intensity care, this occurred farther removed from bladder cancer diagnosis and closer to death. CONCLUSIONS Nearly half of Medicare beneficiaries with bladder cancer who die within 1 year of diagnosis receive high-intensity care at the end of life. Palliative care was seldom used and only very near the time of death.
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Affiliation(s)
- Lee A Hugar
- Department of Genitourinary Oncology, H. Lee Moffitt Cancer Center, Tampa, FL.
| | - Jonathan G Yabes
- Department of Urology, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Pauline Filippou
- Department of Urology, University of Washington School of Medicine, Seattle, WA
| | - Elizabeth M Wulff-Burchfield
- Medical Oncology Division and Palliative Care Division, Department of Internal Medicine, University of Kansas Medical Center, Westwood, KS
| | - Samia H Lopa
- Department of Urology, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - John Gore
- Department of Urology, University of Washington School of Medicine, Seattle, WA
| | - Benjamin J Davies
- Department of Urology, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Bruce L Jacobs
- Department of Urology, University of Pittsburgh School of Medicine, Pittsburgh, PA
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Lee J, Steel J, Roumelioti ME, Erickson S, Myaskovsky L, Yabes JG, Rollman BL, Weisbord S, Unruh M, Jhamb M. Psychosocial Impact of COVID-19 Pandemic on Patients with End-Stage Kidney Disease on Hemodialysis. ACTA ACUST UNITED AC 2020; 1:1390-1397. [DOI: 10.34067/kid.0004662020] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2020] [Accepted: 10/12/2020] [Indexed: 11/27/2022]
Abstract
BackgroundThe coronavirus disease 2019 (COVID-19) may have a negative effect on the mental and social health of patients with ESKD on chronic in-center hemodialysis (HD), who have a high burden of psychologic symptoms at baseline and unavoidable treatment-related COVID exposures. The goal of our study was to assess the effect of the COVID-19 pandemic on the psychosocial health of patients on chronic in-center HD.MethodsParticipants enrolled in the ongoing Technology Assisted Collaborative Care (TĀCcare) trial in Western Pennsylvania and New Mexico were approached for participation in a phone survey in May 2020. Data on the pandemic’s effects on participants’ physical and mental health, symptoms (such as anxiety, mood, loneliness, sleep, and stress), and food and housing security were collected.ResultsSurveys were completed by 49 participants (mean age 56 years; 53% men, 18% Black, 20% American Indian, and 22% Hispanic). Almost 80% of participants reported being moderately to extremely worried about the pandemic’s effects on their mental/emotional health and interpersonal relationships. More than 85% of the participants were worried about obtaining their dialysis treatments due to infection risk from close contact in the dialysis facility or during transportation. Despite this, 82% of participants reported being not at all/slightly interested in trying home dialysis as an alternative option. Overall, 27% of the participants had clinical levels of depressive symptoms but only 12% had anxiety meeting clinical criteria. About 33% of participants reported poor sleep quality over the last month. Perceived stress was high in about 30% of participants and 85% felt overwhelmed by difficulties with COVID-19, although 41% felt that things were fairly/very often going their way.ConclusionsOur study provides preliminary insights into the psychosocial distress caused by the COVID-19 pandemic among a diverse cohort of patients receiving chronic HD who are participating in an ongoing clinical trial.
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Jacobs BL, Rogers D, Yabes JG, Bandari J, Ayyash OM, Maganty A, Armann KM, Worku HA, Pace NM, Shah A, Pekala KR, Yu M, Chelly JE, Macleod LC, Davies BJ. Large reduction in opioid prescribing by a multipronged behavioral intervention after major urologic surgery. Cancer 2020; 127:257-265. [PMID: 33002197 DOI: 10.1002/cncr.33200] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2020] [Revised: 04/15/2020] [Accepted: 06/04/2020] [Indexed: 11/06/2022]
Abstract
BACKGROUND Surgeons play a pivotal role in combating the opioid crisis that currently grips the United States. Changing surgeon behavior is difficult, and the degree to which behavioral science can steer surgeons toward decreased opioid prescribing is unclear. METHODS This was a single-institution, single-arm, pre- and postintervention study examining the prescribing of opioids by urologists for adult patients undergoing prostatectomy or nephrectomy. The primary outcome was the quantity of opioids prescribed in oral morphine equivalents (OMEs) after hospital discharge. The primary exposure was a multipronged behavioral intervention designed to decrease opioid prescribing. The intervention had 3 components: 1) formal education, 2) individual audit feedback, and 3) peer comparison performance feedback. There were 3 phases to the study: a pre-intervention phase, an intervention phase, and a washout phase. RESULTS Three hundred eighty-two patients underwent prostatectomy, and 306 patients underwent nephrectomy. The median OMEs decreased from 195 to 19 in the prostatectomy patients and from 200 to 0 in the nephrectomy patients (P < .05 for both). The median OMEs prescribed did not increase during the washout phase. Prostatectomy patients discharged with opioids had higher levels of anxiety than patients discharged without opioids (P < .05). Otherwise, prostatectomy and nephrectomy patients discharged with and without opioids did not differ in their perception of postoperative pain management, activity levels, psychiatric symptoms, or somatic symptoms (P > .05 for all). CONCLUSIONS Implementing a multipronged behavioral intervention significantly reduced opioid prescribing for patients undergoing prostatectomy or nephrectomy without compromising patient-reported outcomes.
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Affiliation(s)
- Bruce L Jacobs
- Department of Urology, University of Pittsburgh, Pittsburgh, Pennsylvania.,Center for Research on Health Care, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Devin Rogers
- School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Jonathan G Yabes
- Center for Research on Health Care, University of Pittsburgh, Pittsburgh, Pennsylvania.,Division of General Internal Medicine, Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Jathin Bandari
- Department of Urology, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Omar M Ayyash
- Department of Urology, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Avinash Maganty
- Department of Urology, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Kody M Armann
- School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Hermoon A Worku
- School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Natalie M Pace
- School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Anup Shah
- Department of Urology, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Kelly R Pekala
- Department of Urology, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Michelle Yu
- Department of Urology, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Jacques E Chelly
- Department of Anesthesiology, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Liam C Macleod
- Department of Urology, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Benjamin J Davies
- Department of Urology, University of Pittsburgh, Pittsburgh, Pennsylvania
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Shah AA, Kumar P, Ogunmola AG, Ayyash O, Yabes JG, Sabik LM, Odisho AY, Bandari J, Macleod LC, Davies BJ, Jacobs BL. Statewide Price Variation for Generic Benign Prostatic Hyperplasia Medications. Urology 2020; 148:224-229. [PMID: 32961225 DOI: 10.1016/j.urology.2020.08.054] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2020] [Revised: 07/26/2020] [Accepted: 08/31/2020] [Indexed: 11/29/2022]
Abstract
OBJECTIVE To examine the geographic and pharmacy-type variation in costs for generic benign prostatic hyperplasia (BPH) medications in order to improve drug price transparency and reduce health disparities. Medical therapy for BPH can be expensive, having significant implications for uninsured and underinsured patients. METHODS We generated a 20% random sample of all pharmacies in Pennsylvania and queried each for the uninsured cash price of a 30-day prescription of tamsulosin 0.4mg daily, finasteride 5mg daily, oxybutynin immediate release 5mg TID and oxybutynin XL 10mg daily. Our primary objectives were to identify price variation based on pharmacy type (i.e., big chain and independent) and between geographic regions (predetermined by the Pennsylvania Health Care Cost Containment Council Database). We fit multivariable quantile regression models to test for an association between drug price and region after controlling for pharmacy type. RESULTS Among 575 retail pharmacies contacted, 473 responded (82% response rate). The median cash price was significantly higher for big chain pharmacies than for independent pharmacies for tamsulosin ($66 vs. $15), finasteride ($68 vs. $15), oxybutynin immediate release ($49 vs. $35), and oxybutynin XL ($79 vs. $31) (all p < 0.05). When controlling for region, the median and 75th percentile price of all drugs was significantly higher for big chain pharmacies. When controlling for pharmacy type, regional variation was noted in all four drugs at the 75th percentile price and was greater for independent pharmacies. CONCLUSION Compared to independent pharmacies, big chain pharmacies charged significantly more for generic BPH medications to uninsured patients. However, independent pharmacies demonstrated more regional variation in their pricing.
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Affiliation(s)
- Anup A Shah
- Department of Urology, University of Pittsburgh School of Medicine, Pittsburgh, PA.
| | - Praveen Kumar
- Department of Health Policy and Management, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA.
| | | | - Omar Ayyash
- Department of Urology, University of Pittsburgh School of Medicine, Pittsburgh, PA.
| | - Jonathan G Yabes
- Department of Health Policy and Management, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA.
| | - Lindsay M Sabik
- Department of Health Policy and Management, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA.
| | - Anobel Y Odisho
- Department of Urology, School of Medicine, University of California, San Francisco, CA.
| | - Jathin Bandari
- Department of Urology, University of Pittsburgh School of Medicine, Pittsburgh, PA.
| | - Liam C Macleod
- Department of Urology, University of Pittsburgh School of Medicine, Pittsburgh, PA.
| | - Benjamin J Davies
- Department of Urology, University of Pittsburgh School of Medicine, Pittsburgh, PA.
| | - Bruce L Jacobs
- Department of Urology, University of Pittsburgh School of Medicine, Pittsburgh, PA.
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Boutin RD, Katz JR, Chaudhari AJ, Yabes JG, Hirschbein JS, Nakache YP, Seibert JA, Lamba R, Fananapazir G, Canter RJ, Lenchik L. Association of adipose tissue and skeletal muscle metrics with overall survival and postoperative complications in soft tissue sarcoma patients: an opportunistic study using computed tomography. Quant Imaging Med Surg 2020; 10:1580-1589. [PMID: 32742953 DOI: 10.21037/qims.2020.02.09] [Citation(s) in RCA: 16] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
Background To determine the relationship between adipose tissue and skeletal muscle measurements on computed tomography (CT) and overall survival and major postoperative complications in patients with soft-tissue sarcoma (STS). Methods The retrospective study included 137 STS patients (75 men, 62 women; mean age, 53 years, SD 17.7; mean BMI, 28.5, SD 6.6) who had abdominal CT exams. On a single CT image, at the L4 pedicle level, measurements of visceral adipose tissue (VAT), subcutaneous adipose tissue (SAT), and skeletal muscle area and attenuation were obtained using clinical PACS and specialized segmentation software. Clinical information was recorded, including STS characteristics (size, depth, grade, stage, and site), overall survival, and postoperative complications. The relationships between CT metrics and survival were analyzed using Cox proportional hazard models and those between CT metrics and postoperative complications using logistic regression models. Results There were 33 deaths and 41 major postoperative complications. Measured on clinical PACS, the psoas area (P=0.003), psoas index (P=0.006), psoas attenuation (P=0.011), and total muscle attenuation (P=0.023) were associated with overall survival. Using specialized software, psoas attenuation was also associated with overall survival (P=0.018). Adipose tissue metrics were not associated with survival or postoperative complications. Conclusions In STS patients, CT-derived muscle size and attenuation are associated with overall survival. These prognostic biomarkers can be obtained using specialized segmentation software or routine clinical PACS.
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Affiliation(s)
- Robert D Boutin
- Department of Radiology, Stanford University Medical Center, Stanford, CA, USA
| | | | - Abhijit J Chaudhari
- Department of Radiology, University of California, Davis, School of Medicine, Sacramento, CA, USA
| | - Jonathan G Yabes
- Department of Biostatistics, University of Pittsburgh, Pittsburgh, PA, USA
| | | | - Yves-Paul Nakache
- Department of Internal Medicine, Santa Clara Valley Medical Center, San Jose, CA, USA
| | - J Anthony Seibert
- Department of Radiology, University of California, Davis, School of Medicine, Sacramento, CA, USA
| | - Ramit Lamba
- Department of Radiology, University of California, Davis, School of Medicine, Sacramento, CA, USA
| | - Ghaneh Fananapazir
- Department of Radiology, University of California, Davis, School of Medicine, Sacramento, CA, USA
| | - Robert J Canter
- Department of Surgery, University of California, Davis, School of Medicine, Sacramento, CA, USA
| | - Leon Lenchik
- Department of Radiology, Wake Forest School of Medicine, Winston-Salem, NC, USA
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Grajales V, Bandari J, Hale NE, Yabes JG, Turner RM, Fam MM, Sabik LM, Gingrich JR, Davies BJ, Jacobs BL. Associations Between Female Sex and Treatment Patterns and Outcomes for Muscle-invasive Bladder Cancer. Urology 2020; 151:169-175. [PMID: 32673679 DOI: 10.1016/j.urology.2020.06.058] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2020] [Revised: 06/17/2020] [Accepted: 06/28/2020] [Indexed: 11/20/2022]
Abstract
OBJECTIVE To investigate the association of female sex with the selected treatment for patients with nonmetastatic muscle-invasive bladder cancer. Sex is a known independent predictor of death from bladder cancer. A potential explanation for this survival disparity is difference in treatment pattern and stage presentation among males and females. MATERIALS AND METHODS Using the surveillance, epidemiology, and end results-medicare data set, we identified 6809 patients initially diagnosed with nonmetastatic muscle-invasive bladder cancer between 2004 and 2014. We fit multivariable logistic regression and Cox models to assess the relationship of sex with treatment modality and survival adjusting for differences in patient characteristics. RESULTS Of the 6809 patients with nonmetastatic muscle invasive bladder cancer, 2528 (37%) received a radical cystectomy while 4281 (63%) received an alternative bladder sparing intervention. Women were significantly more likely to receive a cystectomy (odds ratios [OR] 1.39; 95% confidence intervals [CI] 1.20-1.61), present at an older age with less comorbidities compared to men (P <.001). Women were also found to have worse bladder cancer-specific survival (CSS) than men (hazard ratio [HR] 1.18; 95% CI 1.05-1.32), no difference in overall survival (OS) (female HR 0.93; 0.86-1.01) and lower mortality from other causes (HR 0.78; 95% CI 0.70-0.86). There were no differences in OS and CSS by sex in patients with stage pT4a. CONCLUSION Female sex predicted more aggressive treatment with radical cystectomy yet worse cancer-specific survival than males. This sex disparity in CSS reduced the known OS advantage observed in women.
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Affiliation(s)
- Valentina Grajales
- Department of Urology, University of Pittsburgh Medical Center, Pittsburgh, PA.
| | - Jathin Bandari
- Department of Urology, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Nathan E Hale
- Department of Urology, Charleston Area Medical Center, Charleston, WV
| | - Jonathan G Yabes
- Department of Medicine, University of Pittsburgh, Pittsburgh, PA
| | - Robert M Turner
- Department of Urology, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Mina M Fam
- Coastal Urology Associates, Hackensack Meridian Health, Brick, NJ
| | - Lindsay M Sabik
- Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA
| | | | - Benjamin J Davies
- Department of Urology, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Bruce L Jacobs
- Department of Urology, University of Pittsburgh Medical Center, Pittsburgh, PA
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Gigli KH, Davis BS, Yabes JG, Chang CCH, Angus DC, Hershey TB, Marin JR, Martsolf GR, Kahn JM. Pediatric Outcomes After Regulatory Mandates for Sepsis Care. Pediatrics 2020; 146:peds.2019-3353. [PMID: 32605994 PMCID: PMC7329251 DOI: 10.1542/peds.2019-3353] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [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] [Accepted: 04/24/2020] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND In 2013, New York introduced regulations mandating that hospitals develop pediatric-specific protocols for sepsis recognition and treatment. METHODS We used hospital discharge data from 2011 to 2015 to compare changes in pediatric sepsis outcomes in New York and 4 control states: Florida, Massachusetts, Maryland, and New Jersey. We examined the effect of the New York regulations on 30-day in-hospital mortality using a comparative interrupted time-series approach, controlling for patient and hospital characteristics and preregulation temporal trends. RESULTS We studied 9436 children admitted to 237 hospitals. Unadjusted pediatric sepsis mortality decreased in both New York (14.0% to 11.5%) and control states (14.4% to 11.2%). In the primary analysis, there was no significant effect of the regulations on mortality trends (differential quarterly change in mortality in New York compared with control states: -0.96%; 95% confidence interval [CI]: -1.95% to 0.02%; P = .06). However, in a prespecified sensitivity analysis excluding metropolitan New York hospitals that participated in earlier sepsis quality improvement, the regulations were associated with improved mortality trends (differential change: -2.08%; 95% CI: -3.79% to -0.37%; P = .02). The regulations were also associated with improved mortality trends in several prespecified subgroups, including previously healthy children (differential change: -1.36%; 95% CI: -2.62% to -0.09%; P = .04) and children not admitted through the emergency department (differential change: -2.42%; 95% CI: -4.24% to -0.61%; P = .01). CONCLUSIONS Implementation of statewide sepsis regulations was generally associated with improved mortality trends in New York State, particularly in prespecified subpopulations of patients, suggesting that the regulations were successful in affecting sepsis outcomes.
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Affiliation(s)
- Kristin H. Gigli
- Clinical Research, Investigation, and Systems Modeling of Acute Illness Center, Department of Critical Care Medicine
| | - Billie S. Davis
- Clinical Research, Investigation, and Systems Modeling of Acute Illness Center, Department of Critical Care Medicine
| | - Jonathan G. Yabes
- Division of General Internal Medicine, Department of Medicine,,Departments of Biostatistics and
| | - Chung-Chou H. Chang
- Division of General Internal Medicine, Department of Medicine,,Departments of Biostatistics and,Health Policy and Management, Graduate School of Public Health, and
| | - Derek C. Angus
- Clinical Research, Investigation, and Systems Modeling of Acute Illness Center, Department of Critical Care Medicine,,Health Policy and Management, Graduate School of Public Health, and
| | | | - Jennifer R. Marin
- Division of Pediatric Emergency Medicine, Department of Pediatrics, School of Medicine
| | - Grant R. Martsolf
- Department of Acute and Tertiary Care, School of Nursing, University of Pittsburgh, Pittsburgh, Pennsylvania; and,RAND Corporation, Pittsburgh, Pennsylvania
| | - Jeremy M. Kahn
- Clinical Research, Investigation, and Systems Modeling of Acute Illness Center, Department of Critical Care Medicine,,Health Policy and Management, Graduate School of Public Health, and
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Buysse DJ, Ritterband LM, Yabes JG, Rollman BL, Strollo PJ, Smith KJ, Patterson CM. 0489 Initial Results from the Hypertension with Unsatisfactory Sleep Health (HUSH) Clinical Trial for Primary Care Patients with Insomnia and Comorbid Hypertension (INS-HTN). Sleep 2020. [DOI: 10.1093/sleep/zsaa056.486] [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: 11/13/2022] Open
Abstract
Abstract
Introduction
Insomnia is commonly comorbid with, and may contribute to, hypertension. Cognitive-behavioral treatments improve insomnia, but their effects on hypertension are uncertain, and they are often unavailable in primary care practices, where most INS-HTN patients are treated. We evaluated the efficacy of Brief Behavioral Treatment for Insomnia (BBTI) and Sleep Healthy Using the Internet (SHUTi) compared to enhanced usual care (EUC) on insomnia and home blood pressure (HBP) in primary care patients with INS-HTN.
Methods
Patients were recruited via electronic health records from 67 primary care practices and randomized 2:2:1 to BBTI delivered via telephone/videoconferencing; SHUTi, an automated, web-based CBT-I program; or EUC including a patient education video. Assessments included self-report questionnaires, home sleep apnea testing, and one week of sleep diary and HBP, measured at Baseline and 9 weeks/ 6 months post-treatment. The primary outcome was the Patient-Reported Outcomes Measurement Information System (PROMIS) Sleep Disturbance scale. Linear mixed models were fitted for continuous variables on the intent-to-treat sample (n=548), adjusting for age and sex. Chi-square tests were used for proportions.
Results
Patients were 61.8±11.3 years old, 67.2% female, and 55.9% were taking hypnotics. Insomnia Severity Index (ISI) was 15.4±4.4, Apnea-Hypopnea Index 9.8±11.4, and HBP 130±14/81±9. BBTI and SHUTi were significantly better than EUC (p≤.002) at 9 weeks and 6 months on PROMIS Sleep Disturbance and Sleep-Related Impairment scales, ISI, and diary sleep efficiency, but had inconsistent effects on PROMIS depression and anxiety scales (p=0.001-0.9). Greater proportions of BBTI and SHUTi vs. EUC-treated patients had 9-week and 6-month ISI scores <8 (p=.01, p=.04) and ISI changes scores ≥7 (p=.002, p=.003). HBP did not significantly differ by intervention group.
Conclusion
BBTI and SHUTi improved insomnia, but did not reduce HBP in patients with INS-HTN. These interventions appear suitable for dissemination and implementation in primary care, but may have limited effects on comorbid symptoms and conditions.
Support
NHLBI UH2/UH3 HL125103
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Affiliation(s)
- D J Buysse
- University of Pittsburgh, Pittsburgh, PA
| | | | - J G Yabes
- University of Pittsburgh, Pittsburgh, PA
| | | | | | - K J Smith
- University of Pittsburgh, Pittsburgh, PA
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Cohen JB, Comer DM, Yabes JG, Ragni MV. Inflammatory Bowel Disease and Thrombosis: A National Inpatient Sample Study. TH Open 2020; 4:e51-e58. [PMID: 32435723 PMCID: PMC7234833 DOI: 10.1055/s-0040-1710506] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2019] [Accepted: 04/07/2020] [Indexed: 12/15/2022] Open
Abstract
Introduction
Thrombosis is more common in inflammatory bowel disease (IBD) patients than the general population, but disease-specific correlates of thrombosis remain unclear.
Methods
We performed a retrospective analysis of discharge data from the National Inpatient Sample between 2009 and 2014, using International Disease Classification codes to identify IBD and non-IBD patients with or without thrombosis. We used NIS-provided discharge-level weights to reflect prevalence estimates. Categoric variables were analyzed by Rao-Scott Chi-square test, continuous variables by weighted simple linear regression, and covariates associated with thrombosis by weighted multivariable logistic regression.
Results
Thrombosis prevalence in IBD was significantly greater than in non-IBD, 7.52 versus 4.54%,
p
< 0.0001. IBD patients with thrombosis were older and more likely to be Caucasian than IBD without thrombosis, each
p
< 0.001. Thrombosis occurred most commonly in the mesenteric vein. Thrombotic risk factors in IBD include surgery, ports, malignancy, dehydration, malnutrition, and steroids at 53.7, 13.2, 13.1, 12.4, 8.9, and 8.2%, respectively. Those with thrombosis had greater severity of illness, 1.42 versus 0.96; length of stay, 7.7 versus 5.5 days; and mortality, 3.8 versus 1.5%; all
p
< 0.0001. Adjusting for age and comorbidity, odds ratios for predictors of thrombosis included ports, steroids, malnutrition, and malignancy at 1.73, 1.61, 1.34, and 1.13, respectively, while Asian race, 0.61, was protective, each
p
< 0.001.
Conclusion
Thrombosis prevalence is 1.7-fold greater in IBD than non-IBD patients. Adjusting for age and comorbidity, the odds ratio for thrombosis in IBD was 73% higher with ports, 61% higher with steroids, 34% with malnutrition, and 13% with malignancy. Whether long-term anticoagulation would benefit the latter is unknown.
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Affiliation(s)
- Jessica B Cohen
- Department of Medicine, Division of Hematology/Oncology, University of Pittsburgh Medical Center and Hemophilia Center of Western Pennsylvania, Pittsburgh, Pennsylvania, United States.,University of Pittsburgh, Pittsburgh, Pennsylvania, United States
| | - Diane M Comer
- University of Pittsburgh Center for Research on Health Care Data Center, Pittsburgh, Pennsylvania, United States
| | - Jonathan G Yabes
- University of Pittsburgh Center for Research on Health Care Data Center, Pittsburgh, Pennsylvania, United States
| | - Margaret V Ragni
- Department of Medicine, Division of Hematology/Oncology, University of Pittsburgh Medical Center and Hemophilia Center of Western Pennsylvania, Pittsburgh, Pennsylvania, United States.,University of Pittsburgh, Pittsburgh, Pennsylvania, United States
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Maganty A, Turner RM, Yabes JG, Heron DE, Gingrich JR, Davies BJ, Jacobs BL. Increasing use of positron emission tomography among medicare beneficiaries undergoing radical cystectomy. Eur J Cancer Care (Engl) 2020; 29:e13230. [PMID: 32026559 DOI: 10.1111/ecc.13230] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2019] [Revised: 12/13/2019] [Accepted: 01/12/2020] [Indexed: 12/22/2022]
Abstract
OBJECTIVE To examine factors associated with PET scan use in the pre-operative evaluation of patients diagnosed with bladder cancer. METHODS Using SEER-Medicare data, we identified bladder cancer patients who underwent radical cystectomy from 2006 to 2011 (n = 4,138). The primary outcome was PET scan use within 6 months before surgery. To examine predictors of PET scan use, we fit a mixed logit model with health service area as a random effect to account for patients nested within health service areas. We also calculated the adjusted probability of use over time and examined variation among the highest volume surgeons. RESULTS Among the 4,138 patients, 406 (10%) received a pre-operative PET scan. The adjusted probability of a patient undergoing a PET scan increased from 0.04 in 2004 to 0.10 in 2011 (p < .001). Among the 78 highest volume surgeons, there was significant variation in PET scan use (p < .001). Patients with non-urothelial histology, measurement of alkaline phosphatase levels, and receipt of neoadjuvant chemotherapy were more likely to receive PET scan (all p < .05). CONCLUSION Use of PET prior to radical cystectomy doubled over a 5-year period, suggesting its increased use in patients with muscle-invasive bladder cancer, particularly those with high-risk disease. Whether its use is warranted and improves patient outcomes is not clear and requires further studies.
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Affiliation(s)
- Avinash Maganty
- Department of Urology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Robert M Turner
- Department of Urology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Jonathan G Yabes
- Division of Internal Medicine, Department of Medicine, University of Pittsburgh, Pittsburgh, PA, USA.,Department of Medicine, Center for Research on Health Care, University of Pittsburgh, Pittsburgh, PA, USA
| | - Dwight E Heron
- Department of Radiation Oncology, University of Pittsburgh Cancer Institute, Pittsburgh, PA, USA
| | | | - Benjamin J Davies
- Department of Urology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Bruce L Jacobs
- Department of Urology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA.,Department of Medicine, Center for Research on Health Care, University of Pittsburgh, Pittsburgh, PA, USA
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Jacobs BL, Yabes JG, Lopa SH, Heron DE, Chang CCH, Bekelman JE, Nelson JB, Bynum JPW, Barnato AE, Kahn JM. Patterns of stereotactic body radiation therapy: The influence of lung cancer treatment on prostate cancer treatment. Urol Oncol 2020; 38:37.e21-37.e27. [PMID: 31699490 PMCID: PMC6954961 DOI: 10.1016/j.urolonc.2019.09.031] [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] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2019] [Revised: 08/30/2019] [Accepted: 09/28/2019] [Indexed: 11/15/2022]
Abstract
INTRODUCTION Technology availability and prior experience with novel cancer treatments may partially drive their use. We sought to examine this issue in the context of stereotactic body radiation therapy (SBRT) by studying how its use for an established indication (lung cancer) impacts its use for an emerging indication (prostate cancer). METHODS Using SEER-Medicare from 2007 to 2011, we developed prostate cancer-specific physician-hospital networks. Our primary dependent variable was SBRT use for prostate cancer and our primary independent variable was SBRT use for lung cancer, both at the network level. To assess the influence of SBRT availability and experiential use, we generated predicted probabilities of SBRT use for prostate cancer stratified by a network's use of lung cancer SBRT, adjusting for network characteristics. To assess intensity of use, we examined the correlation between the proportion of prostate cancer patients and lung cancer patients receiving SBRT within a network. RESULTS We identified 316 networks that served 41,034 prostate cancer and 83,433 lung cancer patients. A network was significantly more likely to use SBRT for prostate cancer if that network used SBRT for lung cancer (e.g., in 2011, odds ratio [OR] 12.7; 95% confidence interval [CI] 3.9-41.8). The Pearson's correlation between the proportion of prostate cancer patients and lung cancer patients receiving SBRT in a network was 0.34, which was not statistically significant (P = 0.12). CONCLUSIONS SBRT availability and experiential use for lung cancer influences its use for prostate cancer, but intensity of use for one does not relate to intensity of use for the other.
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Affiliation(s)
- Bruce L Jacobs
- Department of Urology, University of Pittsburgh, Pittsburgh, PA; Center for Research on Health Care, University of Pittsburgh, Pittsburgh, PA.
| | - Jonathan G Yabes
- Center for Research on Health Care, University of Pittsburgh, Pittsburgh, PA; Division of General Internal Medicine, Department of Medicine, University of Pittsburgh, Pittsburgh, PA
| | - Samia H Lopa
- Department of Urology, University of Pittsburgh, Pittsburgh, PA
| | - Dwight E Heron
- Department of Radiation Oncology-Hillman Cancer Center, University of Pittsburgh, Pittsburgh, PA
| | - Chung-Chou H Chang
- Division of General Internal Medicine, Department of Medicine, University of Pittsburgh, Pittsburgh, PA; Department of Biostatistics, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA
| | - Justin E Bekelman
- Department of Radiation Oncology, University of Pennsylvania, Philadelphia, PA; Division of General Internal Medicine, Abramson Cancer Center, University of Pennsylvania, Philadelphia, PA; Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA
| | - Joel B Nelson
- Department of Urology, University of Pittsburgh, Pittsburgh, PA
| | - Julie P W Bynum
- Department of Medicine, Division of Geriatric and Palliative Medicine, University of Michigan, Ann Arbor, MI
| | - Amber E Barnato
- Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, NH; Dartmouth Institute Geisel School of Medicine, Lebanon, NH
| | - Jeremy M Kahn
- Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA
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Jacobs BL, Yabes JG, Lopa SH, Heron DE, Chang CCH, Bekelman JE, Nelson JB, Bynum JPW, Barnato AE, Kahn JM. The Development and Validation of Prostate Cancer-specific Physician-Hospital Networks. Urology 2020; 138:37-44. [PMID: 31945379 DOI: 10.1016/j.urology.2019.11.049] [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: 08/18/2019] [Revised: 11/16/2019] [Accepted: 11/26/2019] [Indexed: 11/18/2022]
Abstract
OBJECTIVE To develop prostate cancer-specific physician-hospital networks to define hospital-based units that more accurately group hospitals, providers, and the patients they serve. METHODS Using Surveillance, Epidemiology, and End Results-Medicare, we identified men diagnosed with localized prostate cancer between 2007 and 2011. We created physician-hospital networks by assigning each patient to a physician and each physician to a hospital based on treatment patterns. We assessed content validity by examining characteristics of hospitals anchoring the physician-hospital networks and of the patients associated with these hospitals. RESULTS We identified 42,963 patients associated with 344 physician-hospital networks. Networks anchored by a teaching hospital (compared to a nonteaching hospital) had higher median numbers of prostate cancer patients (117 [interquartile range {71-189} vs 82 {50-126}]) and treating physicians (7 [4-11] vs 4 [3-6]) (both P <0.001). On average, patients traveled farther to networks anchored by a teaching hospital (49 miles [standard deviation] [207] vs 41 [183]; P <.001). Hospitals known as high-volume centers for robotic prostatectomies, proton-beam therapy, and active surveillance had network rates for these procedures well above the mean. Hospitals known as safety net providers served higher proportions of minorities. CONCLUSION We empirically developed prostate-cancer specific physician-hospital networks that exhibit content validity and are relevant from a clinical and policy perspective. They have the potential to become targets for policy interventions focused on improving the delivery of prostate cancer care.
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Affiliation(s)
- Bruce L Jacobs
- Department of Urology, University of Pittsburgh, Pittsburgh, PA; Center for Research on Health Care, University of Pittsburgh, Pittsburgh, PA.
| | - Jonathan G Yabes
- Center for Research on Health Care, University of Pittsburgh, Pittsburgh, PA; Division of General Internal Medicine, Department of Medicine, University of Pittsburgh, Pittsburgh, PA
| | - Samia H Lopa
- Department of Urology, University of Pittsburgh, Pittsburgh, PA
| | - Dwight E Heron
- Department of Radiation Oncology, University of Pittsburgh, Pittsburgh, PA
| | - Chung-Chou H Chang
- Division of General Internal Medicine, Department of Medicine, University of Pittsburgh, Pittsburgh, PA; Department of Biostatistics, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA
| | - Justin E Bekelman
- Department of Radiation Oncology, University of Pennsylvania, Philadelphia, PA; Division of General Internal Medicine, Abramson Cancer Center, University of Pennsylvania, Philadelphia, PA; Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA
| | - Joel B Nelson
- Department of Urology, University of Pittsburgh, Pittsburgh, PA
| | - Julie P W Bynum
- Department of Medicine, Division of Geriatric and Palliative Medicine, University of Michigan, Ann Arbor, MI
| | - Amber E Barnato
- Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, NH; Geisel School of Medicine at Dartmouth, Hanover, NH
| | - Jeremy M Kahn
- Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA
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Macleod LC, Fam MM, Yabes JG, Hale NE, Turner RM, Lopa SH, Gingrich JR, Borza T, Skolarus TA, Davies BJ, Jacobs BL. Comparison of Neoadjuvant and Adjuvant Chemotherapy in Muscle-invasive Bladder Cancer. Clin Genitourin Cancer 2019; 18:201-209.e2. [PMID: 31917172 DOI: 10.1016/j.clgc.2019.12.011] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2019] [Revised: 12/05/2019] [Accepted: 12/09/2019] [Indexed: 12/01/2022]
Abstract
BACKGROUND We use observational methods to compare impact of perioperative chemotherapy timing (ie, neoadjuvant and adjuvant) on overall survival (OS) in muscle-invasive bladder cancer because there is no head-to-head randomized trial, and patient factors may influence decision-making. PATIENTS AND METHODS Using Surveillance, Epidemiology, and End Results-Medicare data, we identified patients receiving cystectomy for muscle-invasive bladder cancer diagnosed between 2004 and 2013. Patients were classified as receiving neoadjuvant or adjuvant chemotherapy. Propensity of receiving neoadjuvant chemotherapy was determined using gradient boosted models. Inverse probability of treatment weighted survival curves were adjusted for 13 demographic, socioeconomic, temporal, and oncologic covariates. RESULTS We identified 1342 patients who received neoadjuvant (n = 676) or adjuvant chemotherapy (n = 666) with a median follow-up of 23 months (interquartile range, 9-55 months). Inverse probability of treatment weighted adjustment allows comparison of the groups head-to-head as well as counterfactual scenarios (eg, effect if those getting one treatment were to receive the other). The average treatment effect (ie, "head-to-head" comparison) of adjuvant compared with neoadjuvant on OS was not significant (hazard ratio, 1.14; 95% confidence interval, 0.99-1.31). However, the average treatment effect of the treated (ie, the effect if the neoadjuvant patients were to receive adjuvant instead) was associated with a 33% increase in risk of mortality if they were given adjuvant therapy instead (hazard ratio, 1.33; 95% confidence interval, 1.12-1.57). CONCLUSION Significant treatment selection bias was noted in peri-cystectomy timing, which limits the ability to discriminate differential efficacy of these 2 approaches with observational data. However, patients with higher propensity to receive neoadjuvant therapy were predicted to have increased OS with approach, in keeping with existing paradigms from trial data.
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Affiliation(s)
- Liam C Macleod
- Department of Urology, University of Pittsburgh Medical Center, Pittsburgh, PA; Department of Urology, Asante Rogue Regional Medical Center, Medford, OR.
| | - Mina M Fam
- Department of Urology, Jersey Shore University Medical Center, Neptune, NJ
| | - Jonathan G Yabes
- Department of Medicine, University of Pittsburgh, Pittsburgh, PA
| | - Nathan E Hale
- Department of Urology, Charleston Area Medical Center, Charleston, WV
| | - Robert M Turner
- Department of Urology, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Samia H Lopa
- Department of Medicine, University of Pittsburgh, Pittsburgh, PA
| | | | - Tudor Borza
- Department of Urology, University of Wisconsin, Madison, WI
| | - Ted A Skolarus
- Division of Oncology, Department of Urology, University of Michigan, Ann Arbor, MI; Dow Division for Urologic Health Service Research, Department of Urology, University of Michigan, Ann Arbor, MI; VA Health Services Research & Development, Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI
| | - Benjamin J Davies
- Department of Urology, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Bruce L Jacobs
- Department of Urology, University of Pittsburgh Medical Center, Pittsburgh, PA
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50
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Hale NE, Macleod LC, Yabes JG, Turner RM, Fam MM, Gingrich JR, Skolarus TA, Borza T, Sabik LM, Davies BJ, Jacobs BL. Implications of Cystectomy Travel Distance for Hospital Readmission and Survival. Clin Genitourin Cancer 2019; 17:e1171-e1180. [DOI: 10.1016/j.clgc.2019.08.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2019] [Revised: 08/03/2019] [Accepted: 08/10/2019] [Indexed: 12/19/2022]
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