Getting to the root: Examining within and between home health agency inequities in functional improvement

OBJECTIVE

To quantify racial, ethnic, and income-based disparities in home health (HH) patients' functional improvement within and between HH agencies (HHAs).

DATA SOURCES

2016-2017 Outcome and Assessment Information Set, Medicare Beneficiary Summary File, and Census data.

DATA COLLECTION/EXTRACTION METHODS

Not Applicable.

STUDY DESIGN

We use multinomial-logit analyses with and without HHA fixed effects. The outcome is a mutually exclusive five-category outcome: (1) any functional improvement, (2) no functional improvement, (3) death while a patient, (4) transfer to an inpatient setting, and (5) continuing HH as of December 31, 2017. The adjusted outcome rates are calculated by race, ethnicity, and income level using predictive margins.

PRINCIPAL FINDINGS

Of the 3+ million Medicare beneficiaries with a HH start-of-care assessment in 2016, 77% experienced functional improvement at discharge, 8% were discharged without functional improvement, 0.6% died, 2% were transferred to an inpatient setting, and 12% continued using HH. Adjusting for individual-level characteristics, Black, Hispanic, American Indian/Alaska Native (AIAN), and low-income HH patients were all more likely to be discharged without functional improvement (1.3 pp [95% CI: 1.1, 1.5], 1.5 pp [95% CI: 0.8, 2.1], 1.2 pp [95% CI: 0.6, 1.8], 0.7 pp [95% CI:0.5, 0.8], respectively) compared to White and higher income patients. After including HHA fixed effects, the differences for Black, Hispanic, and AIAN HH patients were mitigated. However, income-based disparities persisted within HHAs. Black-White, Hispanic-White, and AIAN-White disparities were largely driven by between-HHA differences, whereas income-based disparities were mostly due to within-HHA differences, and Asian American/Pacific Islander patients did not experience any observable disparities.

CONCLUSIONS

Both within- and between-HHA differences contribute to the overall disparities in functional improvement. Mitigating functional improvement inequities will require a diverse set of culturally appropriate and socially conscious interventions. Improving the quality of HHAs that serve more marginalized patients and incentivizing improved equity within HHAs are approaches that are imperative for ameliorating outcomes.

Access to preferred skilled nursing facilities: Transitional care pathways for patients with Alzheimer's disease and related dementias

OBJECTIVE

The study aimed to assess whether individuals with Alzheimer's disease and related dementias (ADRD) experience restricted access to hospitals' high-volume preferred skilled nursing facility (SNF) partners.

DATA SOURCES

The data source includes acute care hospital to SNF transitions identified using 100% Medicare Provider Analysis and Review files, 2017-2019.

STUDY DESIGN

We model and compare the estimated effect of facility "preferredness" on SNF choice for patients with and without ADRD. We use conditional logistic regression with a 1:1 patient sample otherwise matched on demographic and encounter characteristics.

DATA COLLECTION

Our matched sample included 58,190 patients, selected from a total observed population of 3,019,260 Medicare hospitalizations that resulted in an SNF transfer between 2017 and 2019.

PRINCIPAL FINDINGS

Overall, patients with ADRD have a lower probability of being discharged to a preferred SNF (52.0% vs. 54.4%, p < 0.001). Choice model estimation using our matched sample suggests similarly that the marginal effect of preferredness on a patient choosing a proximate SNF is 2.4 percentage points lower for patients with ADRD compared with those without (p < 0.001). The differential effect of preferredness based on ADRD status increases when considering (a) the cumulative effect of multiple SNFs in close geographic proximity, (b) the magnitude of the strength of hospital-SNF relationship, and (c) comparing patients with more versus less advanced ADRD.

CONCLUSIONS

Preferred relationships are significantly predictive of where a patient receives SNF care, but this effect is weaker for patients with ADRD. To the extent that these high-volume relationships are indicative of more targeted transitional care improvements from hospitals, ADRD patients may not be fully benefiting from these investments. Hospital leaders can leverage integrated care relationships to reduce SNFs' perceived need to engage in selection behavior (i.e., enhanced resource sharing and transparency in placement practices). Policy intervention may be needed to address selection behavior and to support hospitals in making systemic improvements that can better benefit all SNF partners (i.e., more robust information sharing systems).

Caring for nursing home residents with dementia during the COVID-19 pandemic: Perspectives from administrators

See related Editorial by Unroe and Towsley in this issue.

Administrator Perspectives on the Impact of COVID-19 on the Administration of the Patient Driven Payment Model in U.S. Skilled Nursing Facilities

The Patient Driven Payment Model (PDPM) was implemented in U.S. skilled nursing facilities (SNFs) in October 2019, shortly before COVID-19. This new payment model aimed to reimburse SNFs for patients' nursing needs rather than the previous model which reimbursed based on the volume of therapy received. Through 156 semi-structured interviews with 40 SNF administrators from July 2020 to December 2021, this qualitative study clarifies the impact of COVID-19 on the administration of PDPM at SNFs. Interview data were analyzed using modified grounded theory and thematic analysis. Our findings show that SNF administrators shifted focus from management of the PDPM to COVID-19-related delivery of care adaptations, staff shortfalls, and decreased admissions. As the pandemic abated, administrators re-focused their attention to PDPM. Policy makers should consider the continued impacts of the pandemic at SNFs, particularly on delivery of care, admissions, and staffing, on the ability of SNF administrators to administer a new payment model.

The relationship of age and comorbid conditions to hospital and nursing home days in Medicaid recipients with HIV

OBJECTIVE

To determine how aging impacts health care utilization in persons with HIV (PWH) compared to persons without HIV (PWoH).

DESIGN

Matched case-control study.

METHODS

We studied Medicaid recipients in the United States, aged 18-64 years, from 2001 to 2012. We matched each of 270,074 PWH to three PWoH by baseline year, age, gender, and zip code. Outcomes were hospital and nursing home days per month (DPM). Comorbid condition groups were cardiovascular disease, diabetes, liver disease, mental health conditions, pulmonary disease, and renal disease. We used linear regression to examine the joint relationships of age and comorbid conditions on the two outcomes, stratified by sex at birth.

RESULTS

We found small excesses in hospital DPM for PWH compared with PWoH. There were 0.03 and 0.07 extra hospital DPM for females and males, respectively, and no increases with age. In contrast, excess nursing home DPM for PWH compared with PWoH rose linearly with age, peaking at 0.35 extra days for females and 0.4 extra days for males. HIV-associated excess nursing home DPM were greatest for persons with cardiovascular disease, diabetes, mental health conditions, and renal disease. For PWH at age 55, this represents an 81% increase in the nursing home DPM for males, and a 110% increase for females, compared PWoH.

CONCLUSIONS

Efforts to understand and interrupt this pronounced excess pattern of nursing home DPM among PWH compared to PWoH are needed and may new insights into how HIV and comorbid conditions jointly impact aging with HIV.

Variations in soil physico-chemical properties, soil stocks, and soil stoichiometry under different soil layers, the major forest region Liupan Mountains of Northwest China

Abstract Liupan Mountains are an important region in China in the context of forest cover and vegetation due to huge afforestation and plantation practices, which brought changes in soil physio-chemical properties, soil stocks, and soil stoichiometries are rarely been understood. The study aims to explore the distribution of soil nutrients at 1-m soil depth in the plantation forest region. The soil samples at five depth increments (0-20, 20-40, 40-60, 60-80, and 80-100 cm) were collected and analyzed for different soil physio-chemical characteristics. The results showed a significant variation in soil bulk density (BD), soil porosity, pH, cation exchange capacity (CEC), and electric conductivity (EC) values. More soil BD (1.41 g cm-3) and pH (6.97) were noticed in the deep soil layer (80-100 cm), while the highest values of porosity (60.6%), EC (0.09 mS cm-1), and CEC (32.9 c mol kg-1) were reflected in the uppermost soil layer (0-20 cm). Similarly, the highest contents of soil organic carbon (SOC), total phosphorus (TP), available phosphorus (AP), total nitrogen (TN), and available potassium (AK) were calculated in the surface soil layer (0-20 cm). With increasing soil depth increment a decreasing trend in the SOC and other nutrient concentration were found, whereas the soil total potassium (TK) produced a negative correlation with soil layer depth. The entire results produced the distribution of SOCs and TNs (stocks) at various soil depths in forestland patterns were 0→20cm > 20→40cm > 40→60cm ≥ 60→80cm ≥ 80→100 cm. Furthermore, the stoichiometric ratios of C, N, and P, the C/P, and N/P ratios showed maximum values (66.49 and 5.46) in 0-20 cm and lowest values (23.78 and 1.91) in 80-100 cm soil layer depth. Though the C/N ratio was statistically similar across the whole soil profile (0-100 cm). These results highlighted that the soil depth increments might largely be attributed to fluctuations in soil physio-chemical properties, soil stocks, and soil stoichiometries. Further study is needed to draw more conclusions on nutrient dynamics, soil stocks, and soil stoichiometry in these forests.

Effects of empagliflozin on progression of chronic kidney disease: a prespecified secondary analysis from the empa-kidney trial

BACKGROUND

Sodium-glucose co-transporter-2 (SGLT2) inhibitors reduce progression of chronic kidney disease and the risk of cardiovascular morbidity and mortality in a wide range of patients. However, their effects on kidney disease progression in some patients with chronic kidney disease are unclear because few clinical kidney outcomes occurred among such patients in the completed trials. In particular, some guidelines stratify their level of recommendation about who should be treated with SGLT2 inhibitors based on diabetes status and albuminuria. We aimed to assess the effects of empagliflozin on progression of chronic kidney disease both overall and among specific types of participants in the EMPA-KIDNEY trial.

METHODS

EMPA-KIDNEY, a randomised, controlled, phase 3 trial, was conducted at 241 centres in eight countries (Canada, China, Germany, Italy, Japan, Malaysia, the UK, and the USA), and included individuals aged 18 years or older with an estimated glomerular filtration rate (eGFR) of 20 to less than 45 mL/min per 1·73 m2, or with an eGFR of 45 to less than 90 mL/min per 1·73 m2 with a urinary albumin-to-creatinine ratio (uACR) of 200 mg/g or higher. We explored the effects of 10 mg oral empagliflozin once daily versus placebo on the annualised rate of change in estimated glomerular filtration rate (eGFR slope), a tertiary outcome. We studied the acute slope (from randomisation to 2 months) and chronic slope (from 2 months onwards) separately, using shared parameter models to estimate the latter. Analyses were done in all randomly assigned participants by intention to treat. EMPA-KIDNEY is registered at ClinicalTrials.gov, NCT03594110.

FINDINGS

Between May 15, 2019, and April 16, 2021, 6609 participants were randomly assigned and then followed up for a median of 2·0 years (IQR 1·5-2·4). Prespecified subgroups of eGFR included 2282 (34·5%) participants with an eGFR of less than 30 mL/min per 1·73 m2, 2928 (44·3%) with an eGFR of 30 to less than 45 mL/min per 1·73 m2, and 1399 (21·2%) with an eGFR 45 mL/min per 1·73 m2 or higher. Prespecified subgroups of uACR included 1328 (20·1%) with a uACR of less than 30 mg/g, 1864 (28·2%) with a uACR of 30 to 300 mg/g, and 3417 (51·7%) with a uACR of more than 300 mg/g. Overall, allocation to empagliflozin caused an acute 2·12 mL/min per 1·73 m2 (95% CI 1·83-2·41) reduction in eGFR, equivalent to a 6% (5-6) dip in the first 2 months. After this, it halved the chronic slope from -2·75 to -1·37 mL/min per 1·73 m2 per year (relative difference 50%, 95% CI 42-58). The absolute and relative benefits of empagliflozin on the magnitude of the chronic slope varied significantly depending on diabetes status and baseline levels of eGFR and uACR. In particular, the absolute difference in chronic slopes was lower in patients with lower baseline uACR, but because this group progressed more slowly than those with higher uACR, this translated to a larger relative difference in chronic slopes in this group (86% [36-136] reduction in the chronic slope among those with baseline uACR <30 mg/g compared with a 29% [19-38] reduction for those with baseline uACR ≥2000 mg/g; ptrend<0·0001).

INTERPRETATION

Empagliflozin slowed the rate of progression of chronic kidney disease among all types of participant in the EMPA-KIDNEY trial, including those with little albuminuria. Albuminuria alone should not be used to determine whether to treat with an SGLT2 inhibitor.

FUNDING

Boehringer Ingelheim and Eli Lilly.

Initial Six Month's Study of Neonatal Covid-19 in a Tertiary Care Hospital of Bangladesh

The pandemic Covid-19 affects mainly adult causing fatal illness specially who have co-morbidities. But as days pass by with increasing surveillances it's gradually obvious that this devastating disease also affects the children as well as neonates with greater number. The aim of study was to determine the Covid-19 in neonates. So, we can give proper emphasis on neonatal Covid-19. This cross-sectional study was conducted from April 2020 to September 2020 at Dhaka Shishu (Children) Hospital in Bangladesh. Neonates with suspected Covid-19 were tested for SARS-CoV-2 by RT- PCR. Newborn who had suspected or confirmed COVID-19 mother, exposed to relatives infected with Covid-19, related with cluster outbreak or with abnormal clinical courses such as respiratory distress, not responded to conventional treatment and also abnormal chest x-ray was selected for Covid-19 test. Data regarding gestational age, birth weight, gender, positive cases and other findings were collected and analyzed. Statistics analysis was done by SPSS version 26.0. Forty three cases were Covid-19 positive. Among them 28(65.1%) cases were male and 15(34.9%) female. Term was 39(90.6%) cases and preterm 4(9.4%). Twenty nine (67.5%) cases were belonged to medicine and 14(32.6%) surgical cases. Fourteen (32.5%) cases with Covid-19 lived in Dhaka and 29(67.5%) cases in outside of Dhaka. Eleven (25.5%) cases were positive for SARS -CoV-2 by RT- PCR within 3 days, among them 5 (11.6%) cases were within 24 hours of age. Nine (20.9%) and 23(53.5%) cases were test positive at day 4-7 and 8-28 days respectively. The main symptoms at admission were respiratory difficulty (12/43, 27.9%), fever (8/43, 18.6%), convulsion (8/43, 18.6%) and reluctance to feed (7/43, 16.6%). In neonate two or more diseases coexist in same cases. Sepsis was present in 20 (46.5%) cases with COVID-19. Perinatal asphyxia was present in 10(23.3%) and pneumonia in 8 (18.6%) cases. In laboratory findings low Hb% was present in 2/43(4.7%) cases, leukopenia in 4/43(9.3%), leukocytosis in 2/43(4.7%) and thrombocytopenia in 5/43(11.6%). Elevated CRP was present in 14/29 (32.6%) cases, hypernatremia in 10/33 (30.3%), hyponatremia in 1/33(3%), increased serum creatinine in 10/18(55.6%), and prolonged PT, aPTT in 2/2(100%). Hyperglycaemia was found in 1/15(6.7%) cases and hypoglycaemia in 2/15(13.3%). No organism was found in blood C/S. In chest X-ray, one showed patchy opacities in right lower lobe, another showed bilateral ground-glass opacity and third one revealed few patchy opacities in the right perihilar region. Among 43 cases 21(48.9%) were discharged with advice, 12(27.9%) cases referred to Covid-19 designated hospital, 2(4.7%) cases LAMA (Leave against medical advice) and 8(18.6%) cases died including one surgical case. A good number (43) of Covid-19 cases were found in this study. In neonates the clinical features could not be differentiated properly between Covid-19 or associated diseases unlike children and adult. The neonate may be a source of transmission of this disease. So, we should give proper emphasis on test, tracing and management of neonatal Covid-19.

Impact of primary kidney disease on the effects of empagliflozin in patients with chronic kidney disease: secondary analyses of the EMPA-KIDNEY trial

BACKGROUND

The EMPA-KIDNEY trial showed that empagliflozin reduced the risk of the primary composite outcome of kidney disease progression or cardiovascular death in patients with chronic kidney disease mainly through slowing progression. We aimed to assess how effects of empagliflozin might differ by primary kidney disease across its broad population.

METHODS

EMPA-KIDNEY, a randomised, controlled, phase 3 trial, was conducted at 241 centres in eight countries (Canada, China, Germany, Italy, Japan, Malaysia, the UK, and the USA). Patients were eligible if their estimated glomerular filtration rate (eGFR) was 20 to less than 45 mL/min per 1·73 m2, or 45 to less than 90 mL/min per 1·73 m2 with a urinary albumin-to-creatinine ratio (uACR) of 200 mg/g or higher at screening. They were randomly assigned (1:1) to 10 mg oral empagliflozin once daily or matching placebo. Effects on kidney disease progression (defined as a sustained ≥40% eGFR decline from randomisation, end-stage kidney disease, a sustained eGFR below 10 mL/min per 1·73 m2, or death from kidney failure) were assessed using prespecified Cox models, and eGFR slope analyses used shared parameter models. Subgroup comparisons were performed by including relevant interaction terms in models. EMPA-KIDNEY is registered with ClinicalTrials.gov, NCT03594110.

FINDINGS

Between May 15, 2019, and April 16, 2021, 6609 participants were randomly assigned and followed up for a median of 2·0 years (IQR 1·5-2·4). Prespecified subgroupings by primary kidney disease included 2057 (31·1%) participants with diabetic kidney disease, 1669 (25·3%) with glomerular disease, 1445 (21·9%) with hypertensive or renovascular disease, and 1438 (21·8%) with other or unknown causes. Kidney disease progression occurred in 384 (11·6%) of 3304 patients in the empagliflozin group and 504 (15·2%) of 3305 patients in the placebo group (hazard ratio 0·71 [95% CI 0·62-0·81]), with no evidence that the relative effect size varied significantly by primary kidney disease (pheterogeneity=0·62). The between-group difference in chronic eGFR slopes (ie, from 2 months to final follow-up) was 1·37 mL/min per 1·73 m2 per year (95% CI 1·16-1·59), representing a 50% (42-58) reduction in the rate of chronic eGFR decline. This relative effect of empagliflozin on chronic eGFR slope was similar in analyses by different primary kidney diseases, including in explorations by type of glomerular disease and diabetes (p values for heterogeneity all >0·1).

INTERPRETATION

In a broad range of patients with chronic kidney disease at risk of progression, including a wide range of non-diabetic causes of chronic kidney disease, empagliflozin reduced risk of kidney disease progression. Relative effect sizes were broadly similar irrespective of the cause of primary kidney disease, suggesting that SGLT2 inhibitors should be part of a standard of care to minimise risk of kidney failure in chronic kidney disease.

FUNDING

Boehringer Ingelheim, Eli Lilly, and UK Medical Research Council.

3D Dosimetry for Electron Flash Radiotherapy: Assessment of Radiochromic Dosimeter Phantoms with Optical CT Scanning as a 3D Dosimetry System

PURPOSE/OBJECTIVE(S)

Many of the dosimeters used in conventional radiation therapy exhibit dose rate dependence which prohibits their use in ultra-high-dose-rate (FLASH) radiation therapy. Radiochromic plastic dosimeter PRESAGE® has been used for 3D dosimetry for many years. We hypothesized that these phantoms would show dose-rate independence throughout both the conventional and FLASH RT regimes, indicating these phantoms exhibit qualities useful for relative 3D dosimetry in FLASH electron beams.

MATERIALS/METHODS

FLASH experiments were performed using a commercially available linear accelerator, converted to deliver an ultra-high-dose-rate 10 MeV electron beam. The LINAC delivered approximately 0.7 Gy/pulse for FLASH irradiations. Dose rate was varied from about 40 Gy/s to 240 Gy/s by changing the repetition rate. PRESAGE phantoms were irradiated en face at six FLASH dose rates: 40 Gy/s, 80 Gy/s, 120 Gy/s, 160 Gy/s, 200 Gy/s, and 240 Gy/s. EBT film and scintillator measurements were used to verify dose delivered. The optical response of the PESAGE phantom versus delivered dose was evaluated with various known doses. A novel parallel-beam optical CT scanner, utilizing fiber optic taper for collimated images, was developed for fast, high resolution, and accurate readout of 3D dosimeters. Percent depth dose curves for various FLASH dose rates and conventional dose rate beams were generated and compared based on the optical response versus dose measurements. Percent depth dose curves from Monte Carlo calculation of the presage phantom were also compared.

RESULTS

As shown in Table 1, the percent depth dose as a function of depth for six FLASH dose rates (240-40 Gy/s) are nearly identical, indicating that optical response of PRESAGE is dose-rate independent. The optical density of PRESAGE phantom was confirmed to be linear with absorbed dose for all FLASH dose rates, consistent with the observation at regular treatment dose rates.

CONCLUSION

PRESAGE phantoms show dose-rate independence in electron beams for a wide range of dose rates from conventional to ultra-high-dose-rates, indicating these phantoms can be useful for relative 3D dose measurements in FLASH electron beams. Future experiments will be undertaken as part of the commissioning of a commercially available FLASH radiotherapy unit.

Socioeconomic disparities in diabetes-concordant comorbidity: national health interview survey, 1997-2018

OBJECTIVE

Although social disparities in morbidity and mortality are well-documented, little is known how socioeconomic status (SES) shapes diabetes-concordant comorbidity (DCC). This study examines socioeconomic inequalities in DCC among adults with diabetes in the United States.

STUDY DESIGN

The study incorporated a cross-sectional nationally representative household health survey.

METHODS

This study used data from the National Health Interview Survey, 1997-2018. The analysis included 56,192 adults aged 30 or above with diabetes. Multinomial logistic regression was used to obtain relative risk ratios in gender-stratified models after adjusting for sociodemographic covariates.

RESULTS

The multivariable-adjusted analyses suggest that across all SES indicators and in both men and women, individuals with lower SES had greater odds of DCC than individuals with higher SES. The associations of SES indicators with DCC were larger in magnitude among women than in men. For example, compared to individuals with a college or higher degree, men with less than a high school degree were 2.06 times (95% confidence interval = 1.76-2.41) and women with less than a high school degree were 3.19 times (95% confidence interval = 2.67-3.82) more likely to have 3 or more DCCs. Similar associations were observed for other indicators of SES.

CONCLUSION

Study findings suggest strong social status and gender-based patterns in DCC. Identifying population groups with poor social status may be useful for informing interventions aiming to improve healthcare services of diabetes-related complications.

Advanced practice clinician care and end-of-life outcomes for community- and nursing home-dwelling Medicare beneficiaries with dementia

INTRODUCTION

Older adults with Alzheimer's disease and related dementias (ADRD) often face burdensome end-of-life care transfers. Advanced practice clinicians (APCs)-which include nurse practitioners and physician assistants-increasingly provide primary care to this population. To fill current gaps in the literature, we measured the association between APC involvement in end-of-life care versus hospice utilization and hospitalization for older adults with ADRD.

METHODS

Using Medicare data, we identified nursing home- (N=517,490) and community-dwelling (N=322,461) beneficiaries with ADRD who died between 2016 and 2018. We employed propensity score-weighted regression methods to examine the association between different levels of APC care during their final 9 months of life versus hospice utilization and hospitalization during their final month.

RESULTS

For both nursing home- and community-dwelling beneficiaries, higher APC care involvement associated with lower hospitalization rates and higher hospice rates.

DISCUSSION

APCs are an important group of providers delivering end-of-life primary care to individuals with ADRD.

HIGHLIGHTS

For both nursing home- and community-dwelling Medicare beneficiaries with ADRD, adjusted hospitalization rates were lower and hospice rates were higher for individuals with higher proportions of APC care involvement during their final 9 months of life. Associations between APC care involvement and both adjusted hospitalization rates and adjusted hospice rates persisted when accounting for primary care visit volume.

Examination of Staffing Shortages at US Nursing Homes During the COVID-19 Pandemic

Importance

Staffing shortages have been widely reported in US nursing homes during the COVID-19 pandemic, but traditional quantitative research analyses have found mixed evidence of staffing shortfalls.

Objective

To examine whether nursing home administrator perspectives can provide context for conflicting aggregate staffing reports in US nursing homes during the COVID-19 pandemic.

Design, Setting, and Participants

In a qualitative study, convergent mixed-methods analysis integrating qualitative and quantitative data sets was used. Semistructured qualitative interviews were conducted between July 14, 2020, and December 16, 2021. Publicly available national Payroll Based Journal data were retrieved from January 1, 2020, to September 30, 2022, on 40 US nursing homes in 8 health care markets that varied by region and nursing home use patterns. Staffing and resident measures were derived from Payroll Based Journal data and compared with national trends for 15 436 US nursing homes. Nursing home administrators were recruited for interviews. Of the 40 administrators who consented to participate, 4 were lost to follow-up.

Exposure

Four repeated, semistructured qualitative interviews with participants were conducted. Interview questions focused on the changes noted during the COVID-19 pandemic in nursing homes.

Main Outcomes and Measures

Thematic description of nursing home administrator compensatory strategies to provide context for quantitative analyses on nursing home staffing levels during the COVID-19 pandemic.

Results

A total of 156 interviews were completed with 40 nursing home administrators. Administrators reported experiencing staff shortages during the COVID-19 pandemic and using compensatory strategies, such as overtime, cross-training, staff-to-resident ratio adjustments, use of agency staff, and curtailing admissions, to maintain operations and comply with minimum staffing regulations. Payroll Based Journal data measures graphed from January 1, 2020, to September 30, 2022, supported administrator reports showing that study facilities had reductions in staff hours, increased use of agency staff, and decreased resident census. Findings were similar to national trends.

Conclusions and Relevance

In this qualitative, convergent mixed-methods study, nursing home administrators reported the major staffing strain they experienced at their facilities and the strategies they used to offset staffing shortages. Their experiences provide context to quantitative analyses on aggregate nursing home census data. The short-term compensatory measures administrators used to comply with regulations and maintain operations may be detrimental to the long-term stability of this workforce.

Short-term Treatment Outcome of Patients with Acute ST-elevation Myocardial Infarction in a Tertiary Care Hospital

Outcome of acute ST-elevation myocardial infarction patients varies time to time. The present study was intended to find out the short-term treatment outcome of the patients admitted in hospital. This descriptive study was carried out in Bangabandhu Sheikh Mujib Medical University (BSMMU), Dhaka, Bangladesh from 15 January 2014 to 14 July 2014. A total of 100 patients admitted with Acute ST-elevation Myocardial Infarction confirmed on the presence of the (a) Typical chest pain of acute ST-elevation Myocardial Infarction (b) Electrocardiogram (ECG) evidence of ST segment elevation in two or more contiguous leads (c) Raised cardiac marker (Troponin I) were included in the study. Patients were randomly enrolled according to the inclusion and exclusion criteria and observe for one week. Data were processed and analyzed by using computer bases software SPSS version 19.0. Descriptive statistical methods were applied for data analysis. P value was considered as statistically significant when it is less than 0.05. Short-term treatment outcome of acute ST-elevation myocardial infarction include mechanical, arrhythmic, ischemic and inflammatory sequelae, as well as left ventricular mural thrombus. In addition to these broad categories, heart failure, arrhythmia, death are other common complications of AMI. The initiation of the complications usually results in explicit sign and symptoms of the acute MI patients. Learning of the complications in the post infarction period and the clinical syndromes develop with each complication, will allow the health care worker to evaluate and manage the complication appropriately.

Spillover effect of the Patient Drive Payment Model on skilled nursing facility therapy delivery among Medicare Advantage enrollees

In a multi-payer health care system, economic theory suggests that different payers can impose spillover effects on one another. This study aimed to evaluate the spillover effect of the Patient Driven Payment Model (PDPM) on Medicare Advantage (MA) enrollees, despite it being designed for Traditional Medicare (TM) beneficiaries. We applied a regression discontinuity approach by comparing therapy utilization before and after the implementation of PDPM in October 2019 focusing on patients newly admitted to skilled nursing facilities. The results showed that both TM and MA enrollees experienced a decrease in individual therapy minutes and an increase in non-individual therapy minutes. The estimated reduction in total therapy use was 9 min per day for TM enrollees and 3 min per day for MA enrollees. The effect of PDPM on MA beneficiaries varied depending on the level of MA penetration, with the smallest effect in facilities with the highest MA penetration quartile. In summary, the PDPM had directionally similar effects on therapy utilization for both TM and MA enrollees, but the magnitudes were smaller for MA beneficiaries. These results suggest that policy changes intended for TM beneficiaries may spillover to MA enrollees and should be assessed accordingly.

Role of Doppler Ultrasound in Diagnosis of Hepatocellular Carcinoma with Histopathological Correlation

Hepatocellular carcinoma (HCC) is the fifth most common cancer in the world and the leading cause (possibly third) of cancer mortality. In a present scenario, HCC displays a challenging clinical problem worldwide. Good-quality ultra sound with careful evaluation of the hepatobiliary system can be a screening examination for HCC in patients at risk. The aim of the study was to determine the diagnostic accuracy of the Doppler sonography for differentiation of hepatocellular carcinoma (HCC) from other focal liver lesions. It was a cross-sectional survey, conducted in the Department of Radiology& Imaging, Mymensingh Medical College, Mymensingh, Bangladesh from January 2017 to December 2018. A total of 70 patients with space occupying lesions on ultrasound were included in this study while pregnant women were excluded. All patients were examined by gray scale ultrasonography, color Doppler and FNAC. To visualize the blood flow, standard color Doppler sonography was used for each lesion. Within the lesions, pulsed Doppler samples were assessed whenever possible on the basis of pulsatile flow & finally resistive index (RI) of intra-tumoral and peritumoral arterial flow was studied. After evaluating by Doppler sonography (CDFI and Spectral analysis), FNAC was done and the specimen was sent to the Department of Pathology for Cytopathological examination. Cytopathology were assessed for confirmation of positive and negative cases of HCC. The detection rate of arterial flow in malignant tumors was 85.1% and in benign lesions were 30.4%. Doppler spectrum analysis showed that the resistive index in primary malignant tumors were 0.76±0.12 and in metastatic tumors were 0.80±0.12 and below 0.6 in benign lesions. The difference was significant (p<0.001). This difference was related with its Cytopathological report. The arterial flow identified by CDFI within the liver lesion with RI >0.6 can be regarded as a criterion of malignant tumors and RI<0.6 can be regarded as benign lesions. This study concluded that the combination of color Doppler flow imaging and RI are more useful in differential diagnosis of liver neoplasms.

Socio-economic inequalities in undiagnosed, untreated, and uncontrolled diabetes mellitus in Bangladesh: is there a gender difference?

OBJECTIVES

We aimed to determine: (1) the prevalence and socio-economic distribution of undiagnosed, untreated, and uncontrolled diabetes mellitus (DM); (2) the relationship between socio-economic status (SES) and undiagnosed, untreated, and uncontrolled DM; and (3) if this relationship is mediated by gender.

STUDY DESIGN

Cross-sectional nationally representative household-based survey.

METHODS

We used data from the Bangladesh Demographic Health Survey from 2017 to 18. Our findings were based on the responses of 12,144 individuals aged 18 years and older. As a measure of SES, we focused on standard of living (hereinafter referred to as wealth). The study's outcome variables were prevalence of total (diagnosed + undiagnosed), undiagnosed, untreated, and uncontrolled DM. We used three regression-based approaches-adjusted odds ratio, relative inequality index, and slope inequality index-to assess different aspects of SES differences in the prevalence of total, undiagnosed, untreated, and uncontrolled DM. We used logistic regression analysis to look at the adjusted association between SES and the outcomes after gender stratification to see whether gender status moderates the association between SES and the targeted outcomes.

RESULTS

In our sample analysis, the age-adjusted prevalence of total, undiagnosed, untreated, and uncontrolled DM was 9.1%, 61.4%, 64.7%, and 72.1%, respectively. Females had a higher prevalence of DM and undiagnosed, untreated, and uncontrolled DM than males. When compared to people in the poor SES group, people in the rich and middle SES groups had 2.60 times (95% confidence interval [CI] 2.05-3.29) and 1.47 times (95% CI 1.18-1.83) higher chance of developing DM. When compared to individuals in the poor SES group, those in the rich SES groups were 0.50 (95% CI 0.33-0.77) and 0.55 times (95% CI 0.36-0.85) less likely to have undiagnosed and untreated DM.

CONCLUSIONS

In Bangladesh, rich SES groups were more likely than poor SES groups to have DM, whereas poor SES groups with DM were less likely than rich SES groups to be aware of their disease and obtain treatment. The government and other concerned parties are urged by this study to pay more attention to developing suitable policy measures to reduce the risk of DM, particularly among rich SES groups, as well as targeted efforts to screen for and diagnose DM in socio-economically disadvantaged groups.

Association of Medicaid Financing and Concentration of Assisted Living Residents Dually Eligible for Medicare and Medicaid

This cross-sectional study examines different levels of state Medicaid financing for assisted living and the association with the number of beneficiaries with dual Medicare and Medicaid eligibility who live in assisted living facilities.

Risk of Discharge to Lower-Quality Nursing Homes Among Hospitalized Older Adults With Alzheimer Disease and Related Dementias

IMPORTANCE

Individuals with Alzheimer disease and related dementias (ADRD) frequently require skilled nursing facility (SNF) care following hospitalization. Despite lower SNF incentives to care for the ADRD population, knowledge on how the quality of SNF care differs for those with vs without ADRD is limited.

OBJECTIVE

To examine whether persons with ADRD are systematically admitted to lower-quality SNFs.

DESIGN, SETTING, AND PARTICIPANTS

Cross-sectional analysis of Medicare beneficiaries hospitalized between January 1, 2017, and December 31, 2019, was conducted. Data analysis was performed from January 15 to May 30, 2022. Participants were discharged to a Medicare-certified SNF from a general acute hospital. Patients younger than 65 years, enrolled in Medicare Advantage, and with prior SNF or long-term nursing home use within 1 year of hospitalization were excluded.

EXPOSURES

The quality level of all SNFs available at the patient's discharge, measured using publicly reported 5-star staffing ratings. The 5-star ratings were grouped into 3 levels (1-2 stars [reference category, low-quality], 3 stars [average-quality], and 4-5 stars [high-quality]).

MAIN OUTCOMES AND MEASURES

The outcome was the SNF a patient entered among the possible SNF destinations available at discharge. Differences in the association between SNF quality and SNF entry for patients with and without ADRD were assessed using a conditional logit model, which simultaneously controls for differences in discharging hospital, residential neighborhood, and the other characteristics (eg, postacute care specialization) of all SNFs available at discharge.

RESULTS

The sample included 2 619 464 patients (mean [SD] age, 81.3 [8.6] years; 61% women; 87% were White; 8% were Black; 22% with ADRD). The probability of discharge to higher quality SNFs was lower for patients with ADRD. If the star rating of an SNF was high instead of low, the log-odds of being discharged to it increased by 0.31 for patients with ADRD and by 0.47 for those without ADRD (difference, -0.16; P < .001). The weaker association between quality and entry for patients with ADRD indicates that they are less likely to be discharged to high-quality SNFs.

CONCLUSIONS AND RELEVANCE

The findings of this study suggest that patients with ADRD are more likely to be discharged to lower-quality SNFs. Targeted reforms, such as ADRD-specific compensation adjustments, may be needed to improve access to better SNFs for patients with ADRD.

Prevalence and Associated Risk Factors of Postpartum Anestrus in Dairy Cows of Sylhet District, Bangladesh

The objectives of current study were to assess the prevalence and risk factors associated with postpartum anestrus in lactating dairy cows in Sylhet region, Bangladesh. A total of 420 postpartum cows of different breed and age were selected randomly from different dairy farms in studied area. Structured questionnaire was used to collect data from farm owner on prevalence and risk factors for postpartum anestrus. Observed heat within 60 days after parturition was considered as normal cyclic cows and others were considered as postpartum anestrus. The prevalence of postpartum anestrus was 36.20%. The study shows that older cows take relatively more time for ovarian resumption. Cow’s having first parity shows cyclicity within 60 days of parturition, and postpartum anestrus increases significantly with the advancement of parity. Postpartum anestrus was significantly higher (P< 0.001) in cows with poor (≤1.0) and excessive (>3) body condition scores (BCS), respectively, compared to those with moderate/optimal BCS (2–3). The postpartum cyclicity in cows within 60 days with a history of normal placental expulsion was significantly higher than in the cows with RFM. Ovarian cyclicity was highest (75.92%) among the cows that were maintained in adequate hygienic conditions and lowest (43.51%) in a poor environment. The highest percentage (88.10%) of cows showed postpartum cyclicity with a history of short lactation length (0-150 days) and resumption of postpartum estrous cycle increases significantly with lactation length. Resumption of postpartum estrus cycles in cows takes more time with a history of minimal (<15 liters) daily milk production than the cow with medium (>15-25 liters) daily milk production. Cows get an adequate feed supply (both concentrate and green grass), which shows a positive effect on postpartum cyclicity. Pre and postpartum complications have a significant (p<0.001) effect on the postpartum cyclicity of cows. Endometritis (81.25%) followed by pyometra (75.76%) were recorded as major reproductive obstacles in ovarian resumption, whereas uterine prolapse (70.59%) followed by abortion (61.54%), milk fever (58.33%), stillbirth (58.33%) and dystocia (57.63%) were the major recorded complications in post-partum phase. The study also revealed that the non-restricted suckling period has a significant (p<0.001) negative effect on ovarian resumption. The risk factors including parity, BCS, placental expulsion, hygienic condition, lactation length, daily milk production and management system were significantly (P<0.01) influenced the postpartum cyclicity. Maintaining optimal BCS of cows, proper hygienic and good management practice, and farmer's training on management of cattle reproduction would improve the number of cows for breeding by 60 days postpartum.

Clinico-epidemiological Characteristics of Asymptomatic and Symptomatic COVID-19-Positive Patients in Bangladesh

As of August 15, 2020, Bangladesh lost 3591 lives since the first Coronavirus disease 2019 (COVID-19) case announced on March 8. The objective of the study was to report the clinical manifestation of both symptomatic and asymptomatic COVID-19-positive patients. An online-based cross-sectional survey was conducted for initial recruitment of participants with subsequent telephone interview by the three trained physicians in 237 adults with confirmed COVID-19 infection in Bangladesh. The study period was 27 April to 26th May 2020. Consent was ensured before commencing the interview. Collected data were entered in a pre-designed case record form and subsequently analyzed by SPSS 20.0. The mean±SD age at presentation was 41.59±13.73 years and most of the cases were male (73.0%). A total of 90.29% of patients reside in urban areas. Among the positive cases, 13.1% (n=31) were asymptomatic. Asymptomatic cases were significantly more common in households with 2 to 4 members (p=0.008). Both symptomatic and asymptomatic patients shared similar ages of presentation (p=0.23), gender differences (p=0.30) and co-morbidities (p=0.11). Only 5.3% of patients received ICU care during their treatment. The most frequent presentation was fever (88.3%), followed by cough (69.9%), chest pain (34.5%), body ache (31.1%), and sore throat (30.1%). Thirty-nine percent (n=92) of the patients had co-morbidities, with diabetes and hypertension being the most frequently observed. There has been an upsurge in COVID-19 cases in Bangladesh. Patients were mostly middle-aged and male. Typical presentations were fever and cough. Maintenance of social distancing and increased testing are required to meet the current public health challenge.

THE IMPACT OF PUBLIC REPORTING ON INEQUITIES IN HIGH-QUALITY HOME HEALTH UTILIZATION

Literature suggests that public reporting of quality may exacerbate disparities in access to high-quality post-acute and long-term care for older adults. The objective of this study was to evaluate the impact of the home health (HH) 5-star ratings on changes in high-quality HH agency (HHA) use, by race, ethnicity, income level, and place-based factors. Using a difference-in-differences framework, we found that after introduction of 5-star ratings adjusted rates of high-quality HHA use increased for all HH users, except for Latinx, Asian American/Pacific Islander, and low-income HH users, and disparities in access to high-quality HHAs were exacerbated for each of these groups. Last, we found that users within predominantly Latinx and lower income neighborhoods had a significantly greater decrease in their use of high-quality HHAs. Policymakers should be aware of the potential unintended consequences of public reporting and should consider adding measures of equity to the publicly reported information.

MEDICAID FINANCING AND SEGREGATION OF DUALS IN ASSISTED LIVING

We used 2018 Medicare enrollment data, a national directory of licensed ALs, and Medicaid state policies. We identified a cohort of 474,661 AL residents and a comparison cohort of 58,911,266 community-residing individuals. We compared the distribution of duals across ALs to the distribution of community-dwelling duals across ZIP codes by taking the ratio of AL Gini index for each state over the community Gini index for each state (the “Gini ratio” or GR). On average, states with both waivers and state plans covering services in AL had the lowest Gini ratio (less segregated than community; GR=0.87;) States with no Medicaid financing for AL had the highest Gini ratio (more segregated than community, GR=1.16). Medicaid coverage for home and community-based services in AL is associated with increased access to AL for duals.

STRUCTURAL INEQUITIES IN OUTCOMES FOR DUAL-ELIGIBLE RESIDENTS IN ASSISTED LIVING

We examined the association of AL residents’ dual-eligibility and the concentration of dually eligible residents in AL communities with residents’ risk of hospitalization and long-term nursing home admission. The exposure was dual status interacted with AL concentration: no-duals, minority-duals [<=50%] (reference group), and majority-duals [>50%]. We found that duals in AL have higher risk of hospitalization and nursing home admission than non-duals. For both duals and non-duals, moving to an AL with a high concentration of duals conferred excess risk of hospitalization. Among duals, however, lower concentration of duals in ALs increases risk of long-term nursing home admission for duals, whereas it is protective for non-duals. The association of higher hospitalization with concentration of duals suggests that quality may be a concern in communities that specialize in care for duals. However, majority-duals ALs may be better equipped to provide more comprehensive care as an alternative to nursing homes.

Perspectives of Nursing Home Administrators across the United States During the COVID‐19 Pandemic

OBJECTIVE

To characterize the experiences of nursing home administrators as they manage facilities across the United States during the COVID-19 pandemic.

DATA SOURCES AND STUDY SETTING

We conducted 156 interviews, consisting of four repeated interviews with administrators from 40 nursing homes in eight health care markets across the country from July 2020 through December 2021.

STUDY DESIGN

We subjected the interview transcripts to a rigorous qualitative analysis to identify overarching themes using a modified grounded theory approach to applied thematic analysis.

DATA COLLECTION METHODS

In-depth, semi-structured qualitative interviews were conducted virtually or by phone, and audio-recorded, with participants' consent. Audio recordings were transcribed.

PRINCIPAL FINDINGS

Interviews with nursing home administrators revealed a number of important cross-cutting themes. In interviewing each facility's administrator four times over the course of the pandemic, we heard perspectives regarding the stages of the pandemic, and how they varied by the facility and changed over time. We also heard how policies implemented by federal, state, and local governments to respond to COVID-19 were frequently changing, confusing, and conflicting. Administrators described the effect of COVID-19 and efforts to mitigate it on residents, including how restrictions on activities, communal dining, and visitation resulted in cognitive decline, depression, and weight loss. Administrators also discussed the impact of COVID-19 on staff and staffing levels, reporting widespread challenges in keeping facilities staffed as well as strategies used to hire and retain staff. Administrators described concerns for the sustainability of the nursing home industry resulting from the substantial costs and pressures associated with responding to COVID-19, the reductions in revenue, and the negative impact of how nursing homes appeared in the media.

CONCLUSIONS

Findings from our research reflect nursing home administrator perspectives regarding challenges operating during COVID-19 and have substantial implications for policy and practice.

A Case of Ambiguous Lineage Acute Leukemia Posing Diagnostic Challenge

Introduction/Objective

N/A.

Methods/Case Report

Acute leukemias with ambiguous lineage encompass those leukemias that show no clear evidence of differentiation along a single lineage and account for less than 4% of all cases of acute leukemias and often poses diagnostic dilemma. We present a challenging case of an ambiguous lineage acute leukemia in a previously healthy 27-year-old male, who presented to the ED with acute fever, dyspnea on exertion, nausea and vomiting. A complete blood count (CBC) showed a white blood cell count of 323 × 109/L, Hemoglobin of 3.3 g/dl, Platelet count of 44 × 109/L and a differential count of Neutrophil: 11, Lymphocyte: 31, Monocyte: 02, Band Neutrophil:1, Myelocyte :1, Blast: 54. Bone marrow aspirate smears revealed a heterogenous population of small to large sized blasts comprising 83% of cellularity. They expressed scant to moderate basophilic cytoplasm, high N/C ratio, round to irregular nuclear contour, finely granular chromatin and some with nucleoli. Other lineages were markedly suppressed. Flow cytometric analysis revealed an abnormal blast population (~80% of total) expressing CD34, HLA-DR, Tdt (subset), CD71 (dim) and CD38. In addition, the blasts expressed myeloid associated antigens CD13, MPO (smaller subset), as well as B-cell associated antigens CD19 (dim), cytoplasmic CD22 and cytoplasmic CD79a. They also expressed T-cell associated antigens, CD2, CD3 (smaller subset), CD5 (subset) and CD7 (subset) but negative for cytoplasmic CD3. This unusual pattern of expression posed a challenge as to what type of mixed phenotype leukemia it should be with variable expressions from all three lineage of myeloid, B- and T-cell. Further work-up showed, scattered blasts are also positive for MPO by cytochemical (on aspirate smear) and immunohistochemical stain (on core). The latter also showed negativity for CD3. Based on all these findings, this mixed phenotype acute leukemia (MPAL) was best categorized as MPAL (B/myeloid) over so called “Triphenotypic (B/T/myeloid) acute leukemia”. We considered expression of myeloid and B cell markers as more lineage defining in this case as compared to small subset expressing T lineage marker CD3. This case exemplifies the importance of multimodal comprehensive analysis of acute leukemia, especially in the setting of MPAL with expression of multi- lineage markers posing a diagnostic challenge.

Results (if a Case Study enter NA)

N/A.

Conclusion

N/A.

Impact of higher payments for rural home health episodes on rehospitalizations

PURPOSE

Home health agencies delivering care in rural counties face unique challenges when providing care to older adults; long travel times between each visit can limit the number of patients seen each day. In 2010, Medicare began paying home health (HH) providers 3% more to serve rural beneficiaries without evaluating the policy's impact on patient outcomes.

METHODS

Using 100% Medicare data on postacute HH episodes from 2007 to 2014, we estimated the impact of higher payments on beneficiaries outcomes using difference-in-differences analysis, comparing rehospitalizations between rural and urban postacute HH episodes before and after 2010.

FINDINGS

Our sample included 5.6 million postacute HH episodes (18% rural). In the preperiod, the 30- and 60-day rehospitalization rates for urban HH episodes were 11.30% and 18.23% compared to 11.38% and 18.39% for rural HH episodes. After 2010, 30- and 60-day rehospitalization rates declined, 10.08% and 16.49% for urban HH episodes and 9.87% and 16.08% for rural HH episodes, respectively. The difference-in-difference estimate was 0.29 percentage points (P = .005) and 0.57 percentage points (P < .001) for 30- and 60-day rehospitalization, respectively.

CONCLUSIONS

Increasing payments resulted in a statistically significant reduction in rehospitalizations for rural postacute HH episodes. The add-on payment is set to sunset in 2022 and its impact on access and quality to HH for rural older adults should be reconsidered.

Memory care reduces nursing home admissions among assisted-living residents with dementia

INTRODUCTION

We compare nursing-home and hospital admissions among residents with Alzheimer's disease and related dementias (ADRD) in memory-care assisted living to those in general assisted living.

METHODS

Retrospective study of Medicare beneficiaries with ADRD in large (>25 bed) assisted-living communities. We compared admission to a hospital, to a nursing home, and long-term (>90 day) admission to a nursing home between the two groups, using risk differences and survival analysis.

RESULTS

Residents in memory-care assisted living had a lower adjusted risk of hospitalization (risk difference = -1.8 percentage points [P = .014], hazard ratio = 0.93 [0.87-1.00]), a lower risk of nursing-home admission (risk difference = -2.2 percentage points [P < .001], hazard ratio = 0.87 [-.79-0.95]), and a lower risk of a long-term nursing home admission (risk difference = -1.1 percentage points [P < .001], hazard ratio = 0.71 [0.57-0.88]).

DISCUSSION

Memory care is associated with reduced rates of nursing-home placement, particularly long-term stays, compared to general assisted living.

Making physical examination in medicine user-friendly

Physical examination (PE) techniques used in medical schools appear redundant in several aspects: unnecessarily regimental, lacking in efficiency, and lengthy. Many techniques are sustained solely because of the age-old tradition. This commentary suggests a simplification of PE techniques to make them acceptable to all the stakeholders, such as patients, medical students, and medical teachers. This is especially relevant in this era when imaging is widely used for diagnosis, and the confidence and reliance on PE are declining. Opinions of 10 senior consultants active in medical practice, teaching, and assessment were sought to know their concurrence with the authors' views. Seven of them provided their opinions, which showed considerable agreement with the authors' views regarding PE. All the items presented in this paper are mostly supported by the opinions of the senior consultants, textbooks, and literature. We consider sharing this work with the fraternity worthwhile.

Echocardiographic Evaluation of Cardiac Changes in Patients with Hypothyroidism and the Response to Treatment

Thyroid hormone acts on heart and peripheral vascular system in multiple ways. Most of the cardiac manifestations are reversible with adequate and timely thyroid therapy. Echocardiographic changes are present in patients with untreated hypothyroidism and the changes are reversible with treatment. Aim of the study was to evaluate the structural and functional changes of the heart in hypothyroid patients and its response to treatment. This prospective observational study was performed in the Bangabandhu Sheikh Mujib Medical University, Dhaka, Bangladesh from November 2012 to April 2013. The study included 35 cases and 35 control based on their thyroid hormonal status. The cases were previously untreated for hypothyroidism. By 2D and M-mode echocardiography LV septal wall and posterior wall thickness, LVIDD, LVIDS, LA and Aortic diameter and ejection fraction were measured. Mitral inflow pattern was observed through pulse wave Doppler and peak E velocity, a velocity and E/A ratio were noted. All the observations were noted both in cases and controls and in cases after normalization of hypothyroid status. Echocardiographic variables showed that septal wall and posterior wall thickness, LVIDD and LVIDS were higher in the cases than those in the control group. Left ventricular ejection fraction was lower in case group compared to control group. Of the mitral inflow parameters, a velocity was higher and E/A ratio lower in cases than those in control group. Following treatment of >3 months the septal wall and posterior wall thicknesses were reduced significantly (p<0.001 and p<0.001 respectively) and Left ventricular ejection fraction was also improved significantly (p<0.001) from its baseline status. Of the mitral inflow parameters, E-velocity was significantly increased, A-velocity significantly decreased and E/A ratio significantly increased from their baseline figures (p=0.016, p=0.032 and p<0.001 respectively). Cardiovascular complications of hypothyroidism increase the morbidity of the patients. Results of our study showed importance of early diagnosis and prompt treatment reversed the condition and that will diminish the extent of cardiac complications.

POS0640 REAL-WORLD EFFECTIVENESS AND SAFETY OF GP2015 IN PATIENTS WITH RHEUMATIC DISEASES: FINAL RESULTS OF THE COMPACT STUDY

Background

COMPACT is a non-interventional study evaluating the effectiveness and safety in patients (pts) with rheumatoid arthritis (RA), axial-spondyloarthritis (axSpA) or psoriatic arthritis (PsA) treated with GP2015 (an etanercept [ETN] biosimilar) in real-world conditions.

Objectives

We present the effectiveness and safety data from the final analysis of the COMPACT study for all patient groups.

Methods

Pts aged ≥18 years on treatment with GP2015 were enrolled. Baseline visit corresponded with date of study inclusion and not with date of GP2015 treatment start. Pts were categorised based on prior treatment status: pts on clinical remission or low disease activity under treatment with reference ETN or biosimilar ETN (initial ETN: [iETN]) and switched to GP2015 (Group A) or pts who received non-ETN targeted therapies and switched to GP2015 (Group B) or biologic-naïve pts who started GP2015 after conventional therapy failure (Group C) or DMARD-naïve pts with recent diagnosis of RA considered suitable for treatment initiation with a biologic and started on treatment with GP2015 (Group D). Effectiveness assessments included Disease Activity Score 28-joint count Erythrocyte Sedimentation Rate (DAS28-ESR) or Ankylosing Spondylitis Disease Activity Score (ASDAS) until Month 12 after enrolment (baseline) in the study.

Results

Of the 1466 pts enrolled, 572 were switched from iETN (Group A), 171 were switched from other targeted therapies (Group B), 713 were biologic-naïve (Group C), and 10 were RA DMARD-naïve (Group D). Comorbidities were more frequent in pts with RA (68.7%,) followed by pts with PsA (59.4%) and axSpA (52.1%). After 12 months of treatment with GP2015, pts with RA or PsA achieved comparable DAS28-ESR scores irrespective of whether they switched from iETN, or from other targeted therapies or were biologic-naïve. At Month 12, the mean ASDAS scores were comparable between the treatment groups in pts with axSpA (Table 1). Across all pt groups, no major differences were observed in the disease activity scores between baseline and Month 12 that may be explained by the ongoing GP2015 treatment at the time of enrolment for an observed average of 138 days. Overall, the proportion of patients with at least one adverse event (AE) and serious AE (SAE) was 47.6% and 7.7% in pts who were switched from iETN, 56.7% and 9.9% in pts switched from other targeted therapies, 56% and 8.7% in biologic-naïve pts, and 60% and 0% in DMARD-naïve pts. Rate of injection site reaction was low across the groups (Figure 1).

Table 1.

Effectiveness outcomes in patients treated with GP2015

Effectiveness outcomesGroup AGroup BGroup CGroup DOverall (A-D)RADAS28-ESR, n, mean (SD)N=295N=88N=451N=10N=844Baselinen=259n=70n=392n=8n=7292.5 (1.1)3.6 (1.3)3.3 (1.5)3.8 (1.2)3.0 (1.4)Month 12n=135n=47n=238n=2n=4222.5 (1.3)2.7 (1.0)2.8 (1.4)4.3 (2.5)2.7 (1.3)PsAN=117N=36N=135N=0N=288Baselinen=80n=30n=116-n=2262.1 (1.0)2.9 (1.6)2.9 (1.6)2.6 (1.5)Month 12n=32n=13n=60-n=1052.6 (1.9)2.6 (1.6)2.3 (1.4)2.4 (1.5)AxSpAASDAS, n, mean (SD)N=160N=47N=127N=0N=334Baselinen=77n=18n=59-n=1541.6 (0.6)1.8 (0.8)2.3 (0.9)1.9 (0.8)Month 12n=39n=8n=23-n=701.8 (0.9)1.9 (0.6)1.9 (1.0)1.8 (0.9)

N, total number of patients in the treatment group; n, number of patients with available data at each time point, SD, standard deviation

Figure 1.

Overall safety outcomes in patients treated with GP2015

Figure 1 represents the adverse events reported during GP2015 treatment.

N, total number of patients in the treatment; n, number of patients in each treatment group

Conclusion

The results show comparable disease activity scores between pts who were switched from iETN, pts switched from other targeted therapies and biologic-naïve pts after 12 months of treatment with GP2015. No impact on the effectiveness of ETN was observed in pts with RA, axSpA or PsA who switched to GP2015. No new safety signals were reported.

Disclosure of Interests

Marc Schmalzing Speakers bureau: Novartis, AbbVie, Chugai/Roche, Janssen-Cilag, Lilly, Consultant of: AstraZeneca, Chugai/Roche, Hexal/Sandoz, Gilead, AbbVie, Janssen-Cilag, Boehringer/Ingelheim, Grant/research support from: Chugai/Roche, Boehringer/Ingelheim, Celgene, Medac, Herbert Kellner: None declared, Ayman Askari: None declared, Javier de Toro Santos: None declared, JULIO CESAR VAZQUEZ PEREZ-COLEMAN Speakers bureau: Sandoz, Abbvie, Sanofi, Fresenius, Rosario Foti Speakers bureau: Abbivie, Gilead, Lilly, Pfizer, UCB, Roche, Novartis, Pfizer, UCB, Sławomir Jeka: None declared, Boulos Haraoui Consultant of: Abbvie, Amgen, Fresenius Kabi, Lilly and Pfizer, Grant/research support from: Abbvie, Amgen, Fresenius Kabi, Lilly and Pfizer, Yannick Allanore Consultant of: Sandoz Hexal, Mylan, Astra-Zeneca, Masiur Rahman Employee of: Sandoz Hexal AG, Fabricio Furlan Employee of: Sandoz Hexal AG, Sohaib HACHAICHI Employee of: Sandoz Hexal AG, Tom Sheeran Speakers bureau: Pfizer, UCB, Roche, Consultant of: Novartis, Pfizer, Grant/research support from: Novartis, UCB, Roche

Evaluation of Short Term Outcome of Stapled Transanal Rectal Resection (STARR) for ODS (Obstructed Defecation Syndrome) by Comparing Pre and Post-operative ODS Score

Obstructed defecation syndrome (ODS) is a common anorectal problem and it can be corrected by various surgical approaches but most of these have high recurrence and complication rates. Antonio Longo introduced Stapled transanal rectal resection (STARR) in 2003 as a minimally invasive transanal operation for correction ODS associated with rectocele and or rectal intussusception. This study was designed to assess the short term outcome of Stapled Transanal Rectal Resection (STARR) as a surgical treatment of Obstructed Defecation Syndrome (ODS). This is a quasi experimental study which was carried out in the department of Colorectal Surgery, Bangabandhu Sheikh Mujib Medical University, Dhaka, Bangladesh from May 2016 to June 2017. Seventeen (17) patients were included in the study. Patients with obstructed defecation syndrome and rectocele and or rectal intussusception admitted in the department of Colorectal Surgery were enrolled in the study as per inclusion and exclusion criteria. History, clinical examination, Proctoscopy, Colonoscopy and MR Defecography was done for evaluation of the patients. During evaluation preoperative Longo's ODS score of every patient also determined and compared with postoperative ODS score. The patient was followed up regularly at one, three and six months after each operation. The ODS score in 82.35% patients improved significantly. The postoperative score was high (13-15) only in 02(11.8%) patients probably due to presence of physiological factors. Post-operative defecatory urgency was developed in only 02(11.76%) patients. Major postoperative complication like hemorrhage or rectovaginal fistula did not develop in any patient. STARR is an effective, less invasive and simple procedure for the treatment of ODS with rectocele and/or rectal intussusception without major morbidity but other physiological causes of ODS should exclude preoperatively because its presence makes the surgical intervention fruitless.

Estrogen Status and Trigeminal Ganglion Responses to Jaw Movement

Chronic temporomandibular joint disorders (TMDs) present with pain in the temporomandibular joint (TMJ) and muscles of mastication. Risk factors for TMD include localized joint/muscle inflammation and estrogen status. This study determined whether mild tissue inflammation and estrogen status influenced the responses of trigeminal ganglion neurons to jaw palpation or jaw movement, 2 key diagnostic features of clinical TMD, in adult rats. Neuronal activity was recorded from male rats, ovariectomized (OvX) female rats, and OvX female rats injected with 17β-estradiol 24 h prior to testing (OvXE). Neurons were tested for responses to deep press over the TMJ region and jaw movement in 3 directions (open, protrusion, lateral) 10 d after intra-TMJ injection of a low dose of complete Freund's adjuvant (CFA) or vehicle (sham). Deep press evoked similar responses in all treatment groups. The response magnitude to jaw opening and protrusion was significantly greater for neurons recorded from OvXE CFA-treated rats than from OvX CFA-treated or OvXE sham rats. The responses to lateral movement of the jaw were similar across all treatment groups. Most neurons (70% to 90%) displayed a static response pattern to jaw movement independent of direction. Estradiol treatment also increased the proportion of neurons that were excited by jaw movement in >1 direction as compared with untreated OvX females or males. These results suggest that mild localized inflammation in the TMJ region during periods of elevated estrogen were sufficient to increase the peripheral driving force for jaw movement-evoked hyperalgesia.

A repeating fast radio burst source in a globular cluster

Fast radio bursts (FRBs) are flashes of unknown physical origin¹. The majority of FRBs have been seen only once, although some are known to generate multiple flashes^2,3. Many models invoke magnetically powered neutron stars (magnetars) as the source of the emission^4,5. Recently, the discovery⁶ of another repeater (FRB 20200120E) was announced, in the direction of the nearby galaxy M81, with four potential counterparts at other wavelengths⁶. Here we report observations that localized the FRB to a globular cluster associated with M81, where it is 2 parsecs away from the optical centre of the cluster. Globular clusters host old stellar populations, challenging FRB models that invoke young magnetars formed in a core-collapse supernova. We propose instead that FRB 20200120E originates from a highly magnetized neutron star formed either through the accretion-induced collapse of a white dwarf, or the merger of compact stars in a binary system⁷. Compact binaries are efficiently formed inside globular clusters, so a model invoking them could also be responsible for the observed bursts.

Consumer selection and home health agency quality and patient experience stars

OBJECTIVE

To compare the impact of the introduction of two distinct sets of star ratings, quality of care, and patient experience, on home health agency (HHA) selection.

DATA SOURCES

We utilized 2014-2016 home health Outcome and Assessment Information Set (OASIS) assessments, as well as publicly reported data from the Home Health Compare website.

DATA COLLECTION/EXTRACTION METHODS

We identified a 5% random sample of admissions (186,498 admissions) for new Medicare Fee-for-Service home health users.

STUDY DESIGN

This admission-level assessment compared HHA selection before (July 2014-June 2015) and after (February-December 2016) star ratings were published. We utilized a conditional logit, discrete choice model, which accounted for all HHAs that each patient could have selected (i.e., the choice set) based on ZIP codes. Our explanatory variables of interest were the interactions between star ratings and time period (pre/post stars). We stratified our analyses by race, admission source, and Medicaid eligibility. We adjusted for HHA characteristics and distance between patients' homes and HHAs.

PRINCIPAL FINDINGS

The introduction of star ratings was associated with a 0.88-percentage-point increase in the probability of selecting a high-quality HHA and a 0.81-percentage-point increase in the probability of selecting a highly ranked patient experience HHA. Patients admitted from the community, and black and Medicare-Medicaid dual-eligible beneficiaries experienced larger increases in their likelihood of selecting high-rated agencies than inpatient, white, and nondual beneficiaries.

CONCLUSIONS

The introduction of quality of care and patient experience stars were associated with changes in HHA selection; however, the strength of these relationships was weaker than observed in other health care settings where a single star rating was reported. The introduction of star ratings may mitigate disparities in HHA selection. Our findings highlight the importance of reporting information about quality and satisfaction separately and conducting research to understand the mechanisms driving HHA selection.

Out Of Reach: Inequities In The Use Of High-Quality Home Health Agencies

Patients receiving home health services from high-quality home health agencies often experience fewer adverse outcomes (for example, hospitalizations) than patients receiving services from low-quality agencies. Using administrative data from 2016 and regression analysis, we examined individual- and neighborhood-level racial, ethnic, and socioeconomic factors associated with the use of high-quality home health agencies. We found that Black and Hispanic home health patients had a 2.2-percentage-point and a 2.5-percentage-point lower adjusted probability of high-quality agency use, respectively, compared with their White counterparts within the same neighborhoods. Low-income patients had a 1.2-percentage-point lower adjusted probability of high-quality agency use compared with their higher-income counterparts, whereas home health patients residing in neighborhoods with higher proportions of marginalized residents had a lower adjusted probability of high-quality agency use. Some 40-77 percent of the disparities in high-quality agency use were attributable to neighborhood-level factors. Ameliorating these inequities will require policies that dismantle structural and institutional barriers related to residential segregation.