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Bartels CM, Chen Y, Powell WR, Rosenkranz MA, Bendlin BB, Kramer J, Busse WW, Kind A. Alzheimer's Incidence and Prevalence with and without Asthma: A Medicare cohort study. J Allergy Clin Immunol 2024:S0091-6749(24)00406-8. [PMID: 38670235 DOI: 10.1016/j.jaci.2024.04.008] [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: 09/26/2023] [Revised: 03/22/2024] [Accepted: 04/05/2024] [Indexed: 04/28/2024]
Abstract
BACKGROUND International data suggest that asthma, like other inflammatory diseases, might increase Alzheimer's disease (AD) risk. OBJECTIVE To explore risk pathways and future mitigation strategies by comparing diagnostic claims-based AD incidence and prevalence among US patients with asthma to non-asthma patients. METHODS This cohort study included a national Medicare 20% random sample 2013-2015. Adult patients with >12 months continuous Medicare with asthma were compared to non-asthma subjects overall and as matched. Asthma was defined by one inpatient or two outpatient codes for asthma. The main outcomes were two-year incident or prevalent AD defined as any codes for ICD-9 331.0 or ICD-10 G30.0, G30.1, G30.8, G30.9. RESULTS Among 5,460,732 total beneficiaries, 678,730 patients were identified with baseline asthma and more often identified as Black or Hispanic, were Medicaid eligible, or resided in a highly disadvantaged neighborhood than those without asthma. Two-year incidence of AD was 1.4% with asthma vs 1.1% without; prevalence was 7.8% vs 5.4% (both p=<0.001). Per 100,000 patients over two years, 303 more incident AD diagnoses occurred in asthma, with 2,425 more prevalent cases (p<0.001). Multivariable models showed asthma had greater odds of two-year AD incidence [AOR 1.33 (1.29-1.36); matched 1.2 (1.17-1.24)] and prevalence [AOR 1.48 (1.47-1.50); matched 1.25 (1.22-1.27)). CONCLUSION Asthma was associated with 20-33% increased two-year incidence and 25-48% increased prevalence of claims-based Alzheimer's disease in this nationally representative US sample. Future research should investigate risk pathways of underlying comorbidities and social determinants, as well as whether there are potential asthma treatments that may preserve brain health.
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Affiliation(s)
- Christie M Bartels
- Department of Medicine, Rheumatology Division, University of Wisconsin School of Medicine and Public Health, Madison, WI, US; Center for Health Disparities Research, University of Wisconsin School of Medicine and Public Health, Madison, WI, US.
| | - Yi Chen
- Department of Biostatistics and Medical informatics, University of Wisconsin School of Medicine and Public Health, Madison, WI, US
| | - W Ryan Powell
- Center for Health Disparities Research, University of Wisconsin School of Medicine and Public Health, Madison, WI, US; Department of Medicine, Geriatrics Division, University of Wisconsin School of Medicine and Public Health, Madison, WI, US
| | - Melissa A Rosenkranz
- Department of Psychiatry, University of Wisconsin School of Medicine and Public Health, Madison, WI, US; Center for Healthy Minds, University of Wisconsin-Madison, Madison, WI, US
| | - Barbara B Bendlin
- Center for Health Disparities Research, University of Wisconsin School of Medicine and Public Health, Madison, WI, US; Department of Medicine, Geriatrics Division, University of Wisconsin School of Medicine and Public Health, Madison, WI, US
| | - Joseph Kramer
- Department of Biostatistics and Medical informatics, University of Wisconsin School of Medicine and Public Health, Madison, WI, US
| | - William W Busse
- Department of Medicine, Division of Allergy, Pulmonary, and Critical Care Medicine; University of Wisconsin School of Medicine and Public Health, Madison, WI, US
| | - Amy Kind
- Center for Health Disparities Research, University of Wisconsin School of Medicine and Public Health, Madison, WI, US; Department of Medicine, Geriatrics Division, University of Wisconsin School of Medicine and Public Health, Madison, WI, US
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Schletzbaum M, Powell WR, Garg S, Kramer J, Astor BC, Gilmore-Bykovskyi A, Kind AJ, Bartels CM. Receipt of rheumatology care and lupus-specific labs among young adults with systemic lupus erythematosus: A US Medicare retention in care cohort study. Lupus 2024:9612033241247905. [PMID: 38631342 DOI: 10.1177/09612033241247905] [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] [Indexed: 04/19/2024]
Abstract
OBJECTIVE In systemic lupus erythematosus, poor disease outcomes occur in young adults, patients identifying as Black or Hispanic, and socioeconomically disadvantaged patients. These identities and social factors differentially shape care access and quality that contribute to lupus health disparities in the US. Thus, our objective was to measure markers of care access and quality, including rheumatology visits (longitudinal care retention) and lupus-specific serology testing, by race and ethnicity, neighborhood disadvantage, and geographic context. METHODS This cohort study used a geo-linked 20% national sample of young adult Medicare beneficiaries (ages 18-35) with lupus-coded encounters and a 1-year assessment period. Retention in lupus care required a rheumatology visit in each 6-month period, and serology testing required ≥1 complement or dsDNA antibody test within the year. Multivariable logistic regression models were fit for visit-based retention and serology testing to determine associations with race and ethnicity, neighborhood disadvantage, and geography. RESULTS Among 1,036 young adults with lupus, 39% saw a rheumatologist every 6 months and 28% had serology testing. White beneficiaries from the least disadvantaged quintile of neighborhoods had higher visit-based retention than other beneficiaries (64% vs 30%-60%). Serology testing decreased with increasing neighborhood disadvantage quintile (aOR 0.80; 95% CI 0.71, 0.90) and in the Midwest (aOR 0.46; 0.30, 0.71). CONCLUSION Disparities in care, measured by rheumatology visits and serology testing, exist by neighborhood disadvantage, race and ethnicity, and region among young adults with lupus, despite uniform Medicare coverage. Findings support evaluating lupus care quality measures and their impact on US lupus outcomes.
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Affiliation(s)
- Maria Schletzbaum
- Department of Population Health Sciences, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
- Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - W Ryan Powell
- Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
- Center for Health Disparities Research, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Shivani Garg
- Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Joseph Kramer
- Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
- Center for Health Disparities Research, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Brad C Astor
- Department of Population Health Sciences, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
- Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Andrea Gilmore-Bykovskyi
- Center for Health Disparities Research, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
- Berbee Walsh Department of Emergency Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Amy J Kind
- Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
- Center for Health Disparities Research, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Christie M Bartels
- Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
- Center for Health Disparities Research, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
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Melcher EM, Vilen L, Pfaff A, Lim S, DeWitt A, Powell WR, Bendlin BB, Kind AJH. Deriving life-course residential histories in brain bank cohorts: A feasibility study. Alzheimers Dement 2024. [PMID: 38497250 DOI: 10.1002/alz.13773] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2023] [Revised: 02/05/2024] [Accepted: 02/06/2024] [Indexed: 03/19/2024]
Abstract
INTRODUCTION The exposome is theorized to interact with biological mechanisms to influence risk for Alzheimer's disease but is not well-integrated into existing Alzheimer's Disease Research Center (ADRC) brain bank data collection. METHODS We apply public data tracing, an iterative, dual abstraction and validation process rooted in rigorous historic archival methods, to develop life-course residential histories for 1254 ADRC decedents. RESULTS The median percentage of the life course with an address is 78.1% (IQR 24.9); 56.5% of the sample has an address for at least 75% of their life course. Archivists had 89.7% agreement at the address level. This method matched current residential survey methodology 97.4% on average. DISCUSSION This novel method demonstrates feasibility, reproducibility, and rigor for historic data collection. To our knowledge, this is the first study to show that public data tracing methods for brain bank decedent residential history development can be used to better integrate the social exposome with biobank specimens. HIGHLIGHTS Public data tracing compares favorably to survey-based residential history. Public data tracing is feasible and reproducible between archivists. Archivists achieved 89.7% agreement at the address level. This method identifies residences for nearly 80% of life-years, on average. This novel method enables brain banks to add social characterizations.
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Affiliation(s)
- Eleanna M Melcher
- Department of Population Health Sciences, University of Wisconsin School of Medicine and Public Health, Warf Office Bldg, Madison, USA
- Center for Health Disparities Research, University of Wisconsin School of Medicine and Public Health, UW Hospital and Clinics, Madison, USA
| | - Leigha Vilen
- Center for Health Disparities Research, University of Wisconsin School of Medicine and Public Health, UW Hospital and Clinics, Madison, USA
| | - Aly Pfaff
- Center for Health Disparities Research, University of Wisconsin School of Medicine and Public Health, UW Hospital and Clinics, Madison, USA
| | - Sarah Lim
- Center for Health Disparities Research, University of Wisconsin School of Medicine and Public Health, UW Hospital and Clinics, Madison, USA
| | - Amanda DeWitt
- Center for Health Disparities Research, University of Wisconsin School of Medicine and Public Health, UW Hospital and Clinics, Madison, USA
| | - W Ryan Powell
- Center for Health Disparities Research, University of Wisconsin School of Medicine and Public Health, UW Hospital and Clinics, Madison, USA
- Department of Medicine Division of Geriatrics and Gerontology, University of Wisconsin School of Medicine and Public Health, 1685 Highland Avenue, 5158, Medical Foundation Centennial Building, Madison, USA
| | - Barbara B Bendlin
- Center for Health Disparities Research, University of Wisconsin School of Medicine and Public Health, UW Hospital and Clinics, Madison, USA
- Department of Medicine Division of Geriatrics and Gerontology, University of Wisconsin School of Medicine and Public Health, 1685 Highland Avenue, 5158, Medical Foundation Centennial Building, Madison, USA
- Wisconsin Alzheimer's Disease Research Center, Madison, USA
| | - Amy J H Kind
- Center for Health Disparities Research, University of Wisconsin School of Medicine and Public Health, UW Hospital and Clinics, Madison, USA
- Department of Medicine Division of Geriatrics and Gerontology, University of Wisconsin School of Medicine and Public Health, 1685 Highland Avenue, 5158, Medical Foundation Centennial Building, Madison, USA
- Wisconsin Alzheimer's Disease Research Center, Madison, USA
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Powell WR, Vilen L, Zuelsdorff M, Goutman SA, Salamat S, Rissman RA, Bendlin BB, Kind AJH. Association between military service and Alzheimer's disease neuropathology at autopsy. Alzheimers Dement 2024; 20:1468-1474. [PMID: 37965965 PMCID: PMC10917028 DOI: 10.1002/alz.13520] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2023] [Revised: 09/14/2023] [Accepted: 10/01/2023] [Indexed: 11/16/2023]
Abstract
INTRODUCTION Anti-amyloid therapies are at the forefront of efforts to treat Alzheimer's disease (AD). Identifying amyloid risk factors may aid screening and intervention strategies. While veterans face increased exposure to risk factors, whether they face a greater neuropathologic amyloid burden is not well understood. METHODS Male decedents donating to two Alzheimer's Disease Research Center (ADRC) brain banks from 1986 to 2018 with categorized neuritic plaque density and neurofibrillary tangles (n = 597) were included. Using generalized ordered logistic regression we modeled each outcome's association with military history adjusting for age and death year. RESULTS Having served in the military (60% of sample) is associated with post mortem neuritic amyloid plaque (for each comparison of higher to lower C scores OR = 1.26; 95% confidence interval [CI] = 1.06-1.49) and tau pathology (B score OR = 1.10; 95% CI = 1.08-1.12). DISCUSSION This is the first study, to our knowledge, finding increased levels of verified AD neuropathology in those with military service. Targeted veteran AD therapies is a pressing need.
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Affiliation(s)
- W. Ryan Powell
- Center for Health Disparities ResearchUniversity of Wisconsin School of Medicine and Public HealthMadisonWisconsinUSA
- Department of MedicineGeriatrics DivisionUniversity of Wisconsin School of Medicine and Public HealthMadisonWisconsinUSA
| | - Leigha Vilen
- Center for Health Disparities ResearchUniversity of Wisconsin School of Medicine and Public HealthMadisonWisconsinUSA
| | - Megan Zuelsdorff
- Wisconsin Alzheimer's Disease Research CenterUniversity of Wisconsin School of Medicine and Public HealthMadisonWisconsinUSA
- University of Wisconsin School of NursingMadisonWisconsinUSA
| | | | - Shahriar Salamat
- Department of Neurological SurgeryUniversity of Wisconsin School of Medicine and Public HealthMadisonWisconsinUSA
- Department of Pathology and Laboratory MedicineUniversity of Wisconsin School of Medicine and Public HealthMadisonWisconsinUSA
| | - Robert A. Rissman
- Department of Physiology and NeuroscienceAlzheimer's Therapeutic Research InstituteKeck School of Medicine of the University of Southern CaliforniaSan DiegoCaliforniaUSA
- VA San Diego Healthcare SystemLa JollaCaliforniaUSA
| | - Barbara B. Bendlin
- Center for Health Disparities ResearchUniversity of Wisconsin School of Medicine and Public HealthMadisonWisconsinUSA
- Department of MedicineGeriatrics DivisionUniversity of Wisconsin School of Medicine and Public HealthMadisonWisconsinUSA
- Wisconsin Alzheimer's Disease Research CenterUniversity of Wisconsin School of Medicine and Public HealthMadisonWisconsinUSA
- Wisconsin Alzheimer's InstituteUniversity of Wisconsin School of Medicine and Public HealthMadisonWisconsinUSA
| | - Amy J. H. Kind
- Center for Health Disparities ResearchUniversity of Wisconsin School of Medicine and Public HealthMadisonWisconsinUSA
- Department of MedicineGeriatrics DivisionUniversity of Wisconsin School of Medicine and Public HealthMadisonWisconsinUSA
- Wisconsin Alzheimer's Disease Research CenterUniversity of Wisconsin School of Medicine and Public HealthMadisonWisconsinUSA
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Vitale K, Powell WR, Krekeler BN, Yee J, Rogus-Pulia N. Stratifying Risk of Nonadherence in Lingual Strengthening Dysphagia Rehabilitation. Am J Speech Lang Pathol 2023; 32:2111-2127. [PMID: 37566883 PMCID: PMC10569446 DOI: 10.1044/2023_ajslp-22-00338] [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] [Subscribe] [Scholar Register] [Received: 10/16/2022] [Revised: 01/14/2023] [Accepted: 04/27/2023] [Indexed: 08/13/2023]
Abstract
PURPOSE Exercise-based treatments may improve swallowing safety and efficiency; yet, it is not clearly understood which factors predict nonadherence to recommended treatment protocols. The aim of this study was to construct an algorithm for stratifying risk of nonadherence to a lingual strengthening dysphagia treatment program. METHOD Using recursive partitioning, we created a classification tree built from a pool of sociodemographic, clinical, and functional status indicators to identify risk groups for nonadherence to an intensive lingual strengthening treatment program. Nonadherence, or noncompletion, was defined as not completing two or more follow-up sessions or a final session within 84 days. RESULTS The study cohort consisted of 243 Veterans enrolled in the Intensive Dysphagia Treatment program across six sites from January 2012 to August 2019. The overall rate of nonadherence in this cohort was 38%. The classification tree demonstrated good discriminate validity (C-statistic = 0.74) and contained eight groups from five variables: primary diagnosis, marital status, Penetration-Aspiration Scale (PAS) severity score, race/ethnicity, and age. Nonadherence risk was categorized as high (range: 69%-77%), intermediate (27%-33%), and low risk (≤ 13%-22%). CONCLUSIONS This study identified distinct risk groups for nonadherence to lingual strengthening dysphagia rehabilitation. Additional research is necessary to understand how these factors may drive nonadherence. With external validation and refinement through prospective studies, a clinically relevant risk stratification tool can be developed to identify patients who may be at high risk for nonadherence and provide targeted patient support to mitigate risk and provide for unmet needs.
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Affiliation(s)
- Kailey Vitale
- Geriatric Research Education and Clinical Center, William S. Middleton Memorial Veterans Hospital, Madison, WI
- Division of Geriatrics and Gerontology, Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison
- Department of Otolaryngology, Boston Medical Center, MA
- Department of Otolaryngology-Head and Neck Surgery, Boston University Chobanian & Avedisian School of Medicine, MA
| | - W. Ryan Powell
- Center for Health Disparities Research, University of Wisconsin School of Medicine and Public Health, Madison
| | - Brittany N. Krekeler
- Department of Surgery-Otolaryngology, University of Wisconsin–Madison
- Department of Otolaryngology–Head & Neck Surgery, University of Cincinnati College of Medicine, OH
- Department of Neurology & Rehabilitation Medicine, University of Cincinnati College of Medicine, OH
| | - Joanne Yee
- Geriatric Research Education and Clinical Center, William S. Middleton Memorial Veterans Hospital, Madison, WI
- Division of Geriatrics and Gerontology, Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison
| | - Nicole Rogus-Pulia
- Geriatric Research Education and Clinical Center, William S. Middleton Memorial Veterans Hospital, Madison, WI
- Division of Geriatrics and Gerontology, Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison
- Department of Surgery-Otolaryngology, University of Wisconsin–Madison
- Department of Communication Sciences and Disorders, University of Wisconsin–Madison
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Schletzbaum M, Sweet N, Astor B, Yu A, Powell WR, Gilmore-Bykovskyi A, Kaiksow F, Sheehy A, Kind AJ, Bartels CM. Associations of Postdischarge Follow-Up With Acute Care and Mortality in Lupus: A Medicare Cohort Study. Arthritis Care Res (Hoboken) 2023; 75:1886-1896. [PMID: 36752354 PMCID: PMC10406973 DOI: 10.1002/acr.25097] [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: 03/02/2022] [Revised: 12/06/2022] [Accepted: 01/31/2023] [Indexed: 02/09/2023]
Abstract
OBJECTIVE Patients with systemic lupus erythematosus experience the sixth highest rate of 30-day readmissions among chronic diseases. Timely postdischarge follow-up is a marker of ambulatory care quality that can reduce readmissions in other chronic conditions. Our objective was to test the hypotheses that 1) beneficiaries from populations experiencing health disparities, including patients from disadvantaged neighborhoods, will have lower odds of completed follow-up, and that 2) follow-up will predict longer time without acute care use (readmission, observation stay, or emergency department visit) or mortality. METHODS This observational cohort study included hospitalizations in January-November 2014 from a 20% random sample of Medicare adults. Included hospitalizations had a lupus code, discharge to home without hospice, and continuous Medicare A/B coverage for 1 year before and 1 month after hospitalization. Timely follow-up included visits with primary care or rheumatology within 30 days. Thirty-day survival outcomes were acute care use and mortality adjusted for sociodemographic information and comorbidities. RESULTS Over one-third (35%) of lupus hospitalizations lacked 30-day follow-up. Younger age, living in disadvantaged neighborhoods, and rurality were associated with lower odds of follow-up. Follow-up was not associated with subsequent acute care or mortality in beneficiaries age <65 years. In contrast, follow-up was associated with a 27% higher hazard for acute care use (adjusted hazard ratio [HR] 1.27 [95% confidence interval (95% CI) 1.09-1.47]) and 65% lower mortality (adjusted HR 0.35 [95% CI 0.19-0.67]) among beneficiaries age ≥65 years. CONCLUSION One-third of lupus hospitalizations lacked follow-up, with significant disparities in rural and disadvantaged neighborhoods. Follow-up was associated with increased acute care, but 65% lower mortality in older systemic lupus erythematosus patients. Further development of lupus-specific postdischarge strategies is needed.
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Affiliation(s)
- Maria Schletzbaum
- Department of Population Health Sciences, University of Wisconsin School of Medicine and Public Health, Madison, WI, US
- Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI, US
| | - Nadia Sweet
- Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI, US
| | - Brad Astor
- Department of Population Health Sciences, University of Wisconsin School of Medicine and Public Health, Madison, WI, US
- Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI, US
| | - Ang Yu
- Department of Sociology, University of Wisconsin – Madison, Madison, WI, US
- Center for Demography and Ecology, University of Wisconsin – Madison, Madison, WI, US
| | - W. Ryan Powell
- Center for Health Disparities Research, University of Wisconsin School of Medicine and Public Health, Madison, WI, US
| | - Andrea Gilmore-Bykovskyi
- Center for Health Disparities Research, University of Wisconsin School of Medicine and Public Health, Madison, WI, US
- School of Nursing, University of Wisconsin – Madison, Madison, WI, US
| | - Farah Kaiksow
- Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI, US
- Center for Health Disparities Research, University of Wisconsin School of Medicine and Public Health, Madison, WI, US
| | - Ann Sheehy
- Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI, US
- Center for Health Disparities Research, University of Wisconsin School of Medicine and Public Health, Madison, WI, US
| | - Amy J Kind
- Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI, US
- Center for Health Disparities Research, University of Wisconsin School of Medicine and Public Health, Madison, WI, US
| | - Christie M Bartels
- Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI, US
- Center for Health Disparities Research, University of Wisconsin School of Medicine and Public Health, Madison, WI, US
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Sheehy AM, Locke CFS, Bonk N, Hirsch RL, Powell WR. Health care policy that relies on poor measurement is ineffective: Lessons from the hospital readmissions reduction program. Health Serv Res 2023; 58:549-553. [PMID: 37069733 PMCID: PMC10154160 DOI: 10.1111/1475-6773.14161] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/19/2023] Open
Affiliation(s)
- Ann M. Sheehy
- Division of Hospital Medicine, Department of MedicineCenter for Health Disparities Research, University of Wisconsin School of Medicine and Public HealthMadisonWisconsinUSA
| | - Charles F. S. Locke
- Department of MedicineJohns Hopkins University School of MedicineBaltimoreMarylandUSA
| | - Nicole Bonk
- Division of Hospital Medicine, Department of MedicineUniversity of Wisconsin School of Medicine and Public HealthMadisonWisconsinUSA
| | | | - W. Ryan Powell
- Division of Geriatrics and Gerontology, Department of MedicineCenter for Health Disparities Research, University of Wisconsin School of Medicine and Public HealthMadisonWisconsinUSA
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Taylor L, Gangnon R, Powell WR, Kramer J, Kind AJH, Bartels CM, Brennan MB. Association of rurality and identifying as black with receipt of specialty care among patients hospitalized with a diabetic foot ulcer: a Medicare cohort study. BMJ Open Diabetes Res Care 2023; 11:11/2/e003185. [PMID: 37072336 PMCID: PMC10124219 DOI: 10.1136/bmjdrc-2022-003185] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2022] [Accepted: 03/28/2023] [Indexed: 04/19/2023] Open
Abstract
INTRODUCTION Rural patients with diabetic foot ulcers, especially those identifying as black, face increased risk of major amputation. Specialty care can reduce this risk. However, care disparities might beget outcome disparities. We aimed to determine whether a smaller proportion of rural patients, particularly those identifying as black, receive specialty care compared with the national proportion. RESEARCH DESIGN AND METHODS This 100% national retrospective cohort examined Medicare beneficiaries hospitalized with diabetic foot ulcers (2013-2014). We report observed differences in specialty care, including: endocrinology, infectious disease, orthopedic surgery, plastic surgery, podiatry, or vascular surgery. We used logistic regression to examine possible intersectionality between rurality and race, controlling for sociodemographics, comorbidities, and ulcer severity and including an interaction term between rurality and identifying as black. RESULTS Overall, 32.15% (n=124 487) of patients hospitalized with a diabetic foot ulcer received specialty care. Among rural patients (n=13 100), the proportion decreased to 29.57%. For patients identifying as black (n=21 649), the proportion was 33.08%. Among rural patients identifying as black (n=1239), 26.23% received specialty care. This was >5 absolute percentage points less than the overall cohort. The adjusted OR for receiving specialty care among rural versus urban patients identifying as black was 0.61 (95% CI 0.53 to 0.71), which was lower than that for rural versus urban patients identifying as white (aOR 0.85, 95% CI 0.80 to 0.89). This metric supported a role for intersectionality between rurality and identifying as black. CONCLUSIONS A smaller proportion of rural patients, particularly those identifying as black, received specialty care when hospitalized with a diabetic foot ulcer compared with the overall cohort. This might contribute to known disparities in major amputations. Future studies are needed to determine causality.
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Affiliation(s)
- Lindsay Taylor
- Medicine, University of Wisconsin-Madison, Madison, Wisconsin, USA
| | - Ronald Gangnon
- Population Health, University of Wisconsin-Madison, Madison, Wisconsin, USA
| | - W Ryan Powell
- Medicine, University of Wisconsin-Madison, Madison, Wisconsin, USA
- University of Wisconsin Center for Health Disparities Research, Madison, Wisconsin, USA
| | - Joseph Kramer
- Medicine, University of Wisconsin-Madison, Madison, Wisconsin, USA
- University of Wisconsin Center for Health Disparities Research, Madison, Wisconsin, USA
| | - Amy J H Kind
- Medicine, University of Wisconsin-Madison, Madison, Wisconsin, USA
- University of Wisconsin Center for Health Disparities Research, Madison, Wisconsin, USA
| | | | - Meghan B Brennan
- Medicine, University of Wisconsin-Madison, Madison, Wisconsin, USA
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Gilmore-Bykovskyi A, Zuelsdorff M, Block L, Golden B, Kaiksow F, Sheehy AM, Bartels CM, Kind AJH, Powell WR. Disparities in 30-day readmission rates among Medicare enrollees with dementia. J Am Geriatr Soc 2023. [PMID: 36896859 PMCID: PMC10363234 DOI: 10.1111/jgs.18311] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2022] [Revised: 01/14/2023] [Accepted: 02/14/2023] [Indexed: 03/11/2023]
Abstract
BACKGROUND Readmissions contribute to excessive care costs and burden for people living with dementia. Assessments of racial disparities in readmissions among dementia populations are lacking, and the role of social and geographic risk factors such as individual-level exposure to greater neighborhood disadvantage is poorly understood. We examined the association between race and 30-day readmissions in a nationally representative sample of Black and non-Hispanic White individuals with dementia diagnoses. METHODS This retrospective cohort study used 100% Medicare fee-for-service claims from all 2014 hospitalizations nationwide among Medicare enrollees with dementia diagnosis linked to patient, stay, and hospital factors. The sample consisted of 1,523,142 hospital stays among 945,481 beneficiaries. The relationship between all cause 30-day readmissions and the explanatory variable of self-reported race (Black, non-Hispanic White) was examined via generalized estimating equations approach adjusting for patient, stay, and hospital-level characteristics to model 30-day readmission odds. RESULTS Black Medicare beneficiaries had 37% higher readmission odds compared to White beneficiaries (unadjusted OR 1.37, CI 1.35-1.39). This heightened readmission risk persisted after adjusting for geographic factors (OR 1.33, CI 1.31-1.34), social factors (OR 1.25, CI 1.23-1.27), hospital characteristics (OR 1.24, CI 1.23-1.26), stay-level factors (OR 1.22, CI 1.21-1.24), demographics (OR 1.21, CI 1.19-1.23), and comorbidities (OR 1.16, CI 1.14-1.17), suggesting racially-patterned disparities in care account for a portion of observed differences. Associations varied by individual-level exposure to neighborhood disadvantage such that the protective effect of living in a less disadvantaged neighborhood was associated with reduced readmissions for White but not Black beneficiaries. Conversely, among White beneficiaries, exposure to the most disadvantaged neighborhoods associated with greater readmission rates compared to White beneficiaries residing in less disadvantaged contexts. CONCLUSIONS There are significant racial and geographic disparities in 30-day readmission rates among Medicare beneficiaries with dementia diagnoses. Findings suggest distinct mechanisms underlying observed disparities differentially influence various subpopulations.
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Affiliation(s)
- Andrea Gilmore-Bykovskyi
- Berbee Walsh Department of Emergency Medicine, University of Wisconsin-Madison School of Medicine & Public Health, Madison, Wisconsin, USA
| | - Megan Zuelsdorff
- School of Nursing, University of Wisconsin-Madison School of Medicine & Public Health, Madison, Wisconsin, USA
| | - Laura Block
- Berbee Walsh Department of Emergency Medicine, University of Wisconsin-Madison School of Medicine & Public Health, Madison, Wisconsin, USA.,School of Nursing, University of Wisconsin-Madison School of Medicine & Public Health, Madison, Wisconsin, USA
| | - Blair Golden
- Division of Hospital Medicine, Department of Medicine, University of Wisconsin-Madison School of Medicine & Public Health, Madison, Wisconsin, USA
| | - Farah Kaiksow
- Division of Hospital Medicine, Department of Medicine, University of Wisconsin-Madison School of Medicine & Public Health, Madison, Wisconsin, USA
| | - Ann M Sheehy
- Division of Hospital Medicine, Department of Medicine, University of Wisconsin-Madison School of Medicine & Public Health, Madison, Wisconsin, USA
| | - Christie M Bartels
- Division of Rheumatology, Department of Medicine, University of Wisconsin-Madison School of Medicine & Public Health, Madison, Wisconsin, USA
| | - Amy J H Kind
- Center for Health Disparities Research, University of Wisconsin-Madison, Madison, WI, USA
| | - W Ryan Powell
- Division of Geriatrics, Department of Medicine, University of Wisconsin-Madison School of Medicine & Public Health, Madison, Wisconsin, USA
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10
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Schletzbaum M, Kind AJ, Chen Y, Astor BC, Ardoin SP, Gilmore-Bykovskyi A, Sheehy AM, Kaiksow FA, Powell WR, Bartels CM. Age-Stratified 30-day Rehospitalization and Mortality and Predictors of Rehospitalization Among Patients With Systemic Lupus Erythematosus: A Medicare Cohort Study. J Rheumatol 2023; 50:359-367. [PMID: 35970523 PMCID: PMC9929023 DOI: 10.3899/jrheum.220025] [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: 07/07/2022] [Indexed: 11/22/2022]
Abstract
OBJECTIVE Recent studies suggest young adults with systemic lupus erythematosus (SLE) have high 30-day readmission rates, which may necessitate tailored readmission reduction strategies. To aid in risk stratification for future strategies, we measured 30-day rehospitalization and mortality rates among Medicare beneficiaries with SLE and determined rehospitalization predictors by age. METHODS In a 2014 20% national Medicare sample of hospitalizations, rehospitalization risk and mortality within 30 days of discharge were calculated for young (aged 18-35 yrs), middle-aged (aged 36-64 yrs), and older (aged 65+ yrs) beneficiaries with and without SLE. Multivariable generalized estimating equation models were used to predict rehospitalization rates among patients with SLE by age group using patient, hospital, and geographic factors. RESULTS Among 1.39 million Medicare hospitalizations, 10,868 involved beneficiaries with SLE. Hospitalized young adult beneficiaries with SLE were more racially diverse, were living in more disadvantaged areas, and had more comorbidities than older beneficiaries with SLE and those without SLE. Thirty-day rehospitalization was 36% among young adult beneficiaries with SLE-40% higher than peers without SLE and 85% higher than older beneficiaries with SLE. Longer length of stay and higher comorbidity risk score increased odds of rehospitalization in all age groups, whereas specific comorbid condition predictors and their effect varied. Our models, which incorporated neighborhood-level socioeconomic disadvantage, had moderate-to-good predictive value (C statistics 0.67-0.77), outperforming administrative data models lacking comprehensive social determinants in other conditions. CONCLUSION Young adults with SLE on Medicare had very high 30-day rehospitalization at 36%. Considering socioeconomic disadvantage and comorbidities provided good prediction of rehospitalization risk, particularly in young adults. Young beneficiaries with SLE with comorbidities should be a focus of programs aimed at reducing rehospitalizations.
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Affiliation(s)
- Maria Schletzbaum
- M. Schletzbaum, PhD, B.C. Astor, PhD, MPH, Department of Population Health Sciences, and Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Amy J Kind
- A.J. Kind, MD, PhD, A.M. Sheehy, MD, MS, F.A. Kaiksow MD, MPP, W. Ryan Powell, PhD, MA, C.M. Bartels, MD, MS, Department of Medicine, and Center for Health Disparities Research, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Yi Chen
- Y. Chen, MS, Department of Biostatistics and Medical Informatics, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Brad C Astor
- M. Schletzbaum, PhD, B.C. Astor, PhD, MPH, Department of Population Health Sciences, and Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Stacy P Ardoin
- S.P. Ardoin, MD, MS, Division of Pediatric Rheumatology, Nationwide Children's Hospital, Columbus, Ohio
| | - Andrea Gilmore-Bykovskyi
- A. Gilmore-Bykovskyi, PhD, RN, Center for Health Disparities Research, University of Wisconsin School of Medicine and Public Health, and School of Nursing, University of Wisconsin, Madison, Wisconsin, USA
| | - Ann M Sheehy
- A.J. Kind, MD, PhD, A.M. Sheehy, MD, MS, F.A. Kaiksow MD, MPP, W. Ryan Powell, PhD, MA, C.M. Bartels, MD, MS, Department of Medicine, and Center for Health Disparities Research, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Farah A Kaiksow
- A.J. Kind, MD, PhD, A.M. Sheehy, MD, MS, F.A. Kaiksow MD, MPP, W. Ryan Powell, PhD, MA, C.M. Bartels, MD, MS, Department of Medicine, and Center for Health Disparities Research, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - W Ryan Powell
- A.J. Kind, MD, PhD, A.M. Sheehy, MD, MS, F.A. Kaiksow MD, MPP, W. Ryan Powell, PhD, MA, C.M. Bartels, MD, MS, Department of Medicine, and Center for Health Disparities Research, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Christie M Bartels
- A.J. Kind, MD, PhD, A.M. Sheehy, MD, MS, F.A. Kaiksow MD, MPP, W. Ryan Powell, PhD, MA, C.M. Bartels, MD, MS, Department of Medicine, and Center for Health Disparities Research, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin;
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11
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Kipp R, Kalscheur M, Sheehy AM, Bartels CM, Kind AJH, Powell WR. Race, Sex, and Neighborhood Socioeconomic Disparities in Ablation of Ventricular Tachycardia Within a National Medicare Cohort. J Am Heart Assoc 2022; 11:e027093. [PMID: 36515242 PMCID: PMC9798800 DOI: 10.1161/jaha.122.027093] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Background Ventricular tachycardia (VT) ablation significantly improves our ability to control VT, yet little is known about whether disparities exist in delivery of this technology. Methods and Results Using a national 100% Medicare inpatient data set of beneficiaries admitted with VT from January 1, 2014, through November 30, 2014, multivariable logistic regression techniques were used to examine the sociodemographic and clinical characteristics associated with receiving ablation. Census block group-level neighborhood socioeconomic disadvantage was measured for each patient by the Area Deprivation Index, a composite measure of socioeconomic disadvantage consisting of education, income, housing, and employment factors. Among 131 645 patients admitted with VT, 2190 (1.66%) received ablation. After adjustment for comorbidities, hospital characteristics, and sociodemographics, female sex (odds ratio [OR], 0.75 [95% CI, 0.67-0.84]), identifying as Black race (OR, 0.75 [95% CI, 0.62-0.90] compared with identifying as White race), and living in a highly socioeconomically disadvantaged neighborhood (national Area Deprivation Index percentile of >85%) (OR, 0.81 [95% CI, 0.69-0.95] versus Area Deprivation Index ≤85%) were associated with significantly lower odds of receiving ablation. Conclusions Female patients, patients identifying as Black race, and patients living in the most disadvantaged neighborhoods are 19% to 25% less likely to receive ablation during hospitalization with VT. The cause of and solutions for these disparities require further investigation.
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Affiliation(s)
- Ryan Kipp
- Division of Cardiovascular Medicine, Department of MedicineUniversity of Wisconsin School of Medicine and Public HealthMadisonWI,William S. Middleton Memorial Veterans HospitalMadisonWI
| | - Matthew Kalscheur
- Division of Cardiovascular Medicine, Department of MedicineUniversity of Wisconsin School of Medicine and Public HealthMadisonWI,William S. Middleton Memorial Veterans HospitalMadisonWI
| | - Ann M. Sheehy
- Division of Hospitalist Medicine, Department of MedicineUniversity of Wisconsin School of Medicine and Public HealthMadisonWI
| | - Christie M. Bartels
- Division of Rheumatology, Department of MedicineUniversity of Wisconsin School of Medicine and Public HealthMadisonWI
| | - Amy J. H. Kind
- Center for Health Disparities Research, University of Wisconsin School of Medicine and Public HealthMadisonWI,Division of Geriatric Medicine, Department of MedicineUniversity of Wisconsin School of Medicine and Public HealthMadisonWI
| | - W. Ryan Powell
- Center for Health Disparities Research, University of Wisconsin School of Medicine and Public HealthMadisonWI
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12
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Kaiksow FA, Powell WR, Locke CF, Caponi B, Kind AJH, Sheehy AM. Improving healthcare value: Addressing the confusing costs of observation hospitalizations. J Hosp Med 2022; 17:757-759. [PMID: 35535936 PMCID: PMC9394737 DOI: 10.1002/jhm.2728] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2021] [Revised: 10/21/2021] [Accepted: 11/24/2021] [Indexed: 11/08/2022]
Affiliation(s)
- Farah Acher Kaiksow
- Drs. Kaiksow and Powell are co-first authors on this manuscript
- Division of Hospital Medicine, Department of Medicine, University of Wisconsin-Madison School of Medicine and Public Health
- Health Services and Care Research Program, Department of Medicine, University of Wisconsin-Madison School of Medicine and Public Health
| | - W. Ryan Powell
- Drs. Kaiksow and Powell are co-first authors on this manuscript
- Health Services and Care Research Program, Department of Medicine, University of Wisconsin-Madison School of Medicine and Public Health
- Division of Geriatrics, Department of Medicine, University of Wisconsin-Madison School of Medicine and Public Health
| | - Charles F. Locke
- Division of General Internal Medicine, Department of Medicine, Johns Hopkins University School of Medicine
| | - Bartho Caponi
- Division of Hospital Medicine, Department of Medicine, University of Wisconsin-Madison School of Medicine and Public Health
| | - Amy J. H. Kind
- Health Services and Care Research Program, Department of Medicine, University of Wisconsin-Madison School of Medicine and Public Health
- Division of Geriatrics, Department of Medicine, University of Wisconsin-Madison School of Medicine and Public Health
| | - Ann M. Sheehy
- Division of Hospital Medicine, Department of Medicine, University of Wisconsin-Madison School of Medicine and Public Health
- Health Services and Care Research Program, Department of Medicine, University of Wisconsin-Madison School of Medicine and Public Health
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13
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Powell WR, Kaiksow FA, Mullahy J, Golden BP, Kind AJH, Sheehy AM. Placing Medicare Beneficiaries at Financial Risk: the Cost of Observation, Inpatient Hospitalization, and Neighborhood Disadvantage. J Gen Intern Med 2022; 37:2601-2603. [PMID: 34981362 PMCID: PMC9360255 DOI: 10.1007/s11606-021-07236-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2021] [Accepted: 10/19/2021] [Indexed: 11/30/2022]
Affiliation(s)
- W Ryan Powell
- University of Wisconsin School of Medicine and Public Health, Madison, WI, USA. .,Center for Health Disparities Research, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA. .,Health Services and Care Research Program, Department of Medicine, School of Medicine and Public Health, University of Wisconsin, Madison, WI, USA.
| | - Farah A Kaiksow
- Health Services and Care Research Program, Department of Medicine, School of Medicine and Public Health, University of Wisconsin, Madison, WI, USA.,Division of Hospital Medicine, Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - John Mullahy
- Department of Population Health Sciences, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Blair P Golden
- Health Services and Care Research Program, Department of Medicine, School of Medicine and Public Health, University of Wisconsin, Madison, WI, USA.,Division of Hospital Medicine, Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Amy J H Kind
- Center for Health Disparities Research, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA.,Health Services and Care Research Program, Department of Medicine, School of Medicine and Public Health, University of Wisconsin, Madison, WI, USA.,Division of Geriatrics and Gerontology, Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA.,Department of Veterans Affairs Geriatrics Research Education and Clinical Center, Madison, WI, USA
| | - Ann M Sheehy
- Health Services and Care Research Program, Department of Medicine, School of Medicine and Public Health, University of Wisconsin, Madison, WI, USA.,Division of Hospital Medicine, Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
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14
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Powell WR, Zuelsdorff M, Keller SA, Betthauser TJ, Rissman RA, Bendlin BB, Kind AJH. Association of Neighborhood-Level Disadvantage With Neurofibrillary Tangles on Neuropathological Tissue Assessment. JAMA Netw Open 2022; 5:e228966. [PMID: 35482313 PMCID: PMC9051985 DOI: 10.1001/jamanetworkopen.2022.8966] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
This cross-sectional study evaluates income, educational level, employment status, and neighborhood and their association with brain changes in decedents with Alzheimer disease and related dementias.
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Affiliation(s)
- W. Ryan Powell
- Center for Health Disparities Research, University of Wisconsin School of Medicine and Public Health, Madison
| | - Megan Zuelsdorff
- Wisconsin Alzheimer’s Disease Research Center, University of Wisconsin School of Medicine and Public Health, Madison
- University of Wisconsin School of Nursing, Madison
| | - Sarah A. Keller
- Center for Health Disparities Research, University of Wisconsin School of Medicine and Public Health, Madison
| | - Tobey J. Betthauser
- Wisconsin Alzheimer’s Disease Research Center, University of Wisconsin School of Medicine and Public Health, Madison
- Department of Medicine, Geriatrics Division, University of Wisconsin School of Medicine and Public Health, Madison
| | - Robert A. Rissman
- Department of Neurosciences, University of California, San Diego
- Shiley-Marcos Alzheimer's Disease Research Center, University of California, San Diego, La Jolla
| | - Barbara B. Bendlin
- Center for Health Disparities Research, University of Wisconsin School of Medicine and Public Health, Madison
- Wisconsin Alzheimer’s Disease Research Center, University of Wisconsin School of Medicine and Public Health, Madison
- Department of Medicine, Geriatrics Division, University of Wisconsin School of Medicine and Public Health, Madison
- Wisconsin Alzheimer’s Institute, University of Wisconsin School of Medicine and Public Health, Madison
- Geriatric Research Education and Clinical Center, William S. Middleton Hospital, Department of Veterans Affairs, Madison, Wisconsin
| | - Amy J. H. Kind
- Center for Health Disparities Research, University of Wisconsin School of Medicine and Public Health, Madison
- Wisconsin Alzheimer’s Disease Research Center, University of Wisconsin School of Medicine and Public Health, Madison
- Department of Medicine, Geriatrics Division, University of Wisconsin School of Medicine and Public Health, Madison
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15
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Powell WR, Hansmann KJ, Carlson A, Kind AJ. Evaluating How Safety-Net Hospitals Are Identified: Systematic Review and Recommendations. Health Equity 2022; 6:298-306. [PMID: 35557553 PMCID: PMC9081065 DOI: 10.1089/heq.2021.0076] [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] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/07/2022] [Indexed: 11/12/2022] Open
Abstract
Objective: To systematically review how safety-net hospitals' status is identified and defined, discuss current definitions' limitations, and provide recommendations for a new classification and evaluation framework. Data Sources: Safety-net hospital-related studies in the MEDLINE database published before May 16, 2019. Study Design: Systematic review of the literature that adheres to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Data Collection/Extraction Methods: We followed standard selection protocol, whereby studies went through an abstract review followed by a full-text screening for eligibility. For each included study, we extracted information about the identification method itself, including the operational definition, the dimension(s) of disadvantage reflected, study objective, and how safety-net status was evaluated. Principal Findings: Our review identified 132 studies investigating safety-net hospitals. Analysis of identification methodologies revealed substantial heterogeneity in the ways disadvantage is defined, measured, and summarized at the hospital level, despite a 4.5-fold increase in studies investigating safety-net hospitals for the past decade. Definitions often exclusively used low-income proxies captured within existing health system data, rarely incorporated external social risk factor measures, and were commonly separated into distinct safety-net status categories when analyzed. Conclusions: Consistency in research and improvement in policy both require a standard definition for identifying safety-net hospitals. Yet no standardized definition of safety-net hospitals is endorsed and existing definitions have key limitations. Moving forward, approaches rooted in health equity theory can provide a more holistic framework for evaluating disadvantage at the hospital level. Furthermore, advancements in precision public health technologies make it easier to incorporate detailed neighborhood-level social determinants of health metrics into multidimensional definitions. Other countries, including the United Kingdom and New Zealand, have used similar methods of identifying social need to determine more accurate assessments of hospital performance and the development of policies and targeted programs for improving outcomes.
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Affiliation(s)
- W. Ryan Powell
- Center for Health Disparities Research, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Kellia J. Hansmann
- Center for Health Disparities Research, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
- Department of Family Medicine and Community Health, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Andrew Carlson
- University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Amy J.H. Kind
- Center for Health Disparities Research, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
- Geriatrics Division, Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
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16
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Brennan MB, Powell WR, Kaiksow F, Kramer J, Liu Y, Kind AJH, Bartels CM. Association of Race, Ethnicity, and Rurality With Major Leg Amputation or Death Among Medicare Beneficiaries Hospitalized With Diabetic Foot Ulcers. JAMA Netw Open 2022; 5:e228399. [PMID: 35446395 PMCID: PMC9024392 DOI: 10.1001/jamanetworkopen.2022.8399] [Citation(s) in RCA: 25] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
IMPORTANCE Patients identifying as Black and those living in rural and disadvantaged neighborhoods are at increased risk of major (above-ankle) leg amputations owing to diabetic foot ulcers. Intersectionality emphasizes that the disparities faced by multiply marginalized people (eg, rural US individuals identifying as Black) are greater than the sum of each individual disparity. OBJECTIVE To assess whether intersecting identities of Black race, ethnicity, rural residence, or living in a disadvantaged neighborhood are associated with increased risk in major leg amputation or death among Medicare beneficiaries hospitalized with diabetic foot ulcers. DESIGN, SETTING, AND PARTICIPANTS This retrospective cohort study used 2013-2014 data from the US National Medicare Claims Data Database on all adult Medicare patients hospitalized with a diabetic foot ulcer. Statistical analysis was conducted from August 1 to October 27, 2021. EXPOSURES Race was categorized using Research Triangle Institute variables. Rurality was assigned using Rural-Urban Commuting Area codes. Residents of disadvantaged neighborhoods comprised those living in neighborhoods at or above the national 80th percentile Area Deprivation Index. MAIN OUTCOMES AND MEASURES Major leg amputation or death during hospitalization or within 30 days of hospital discharge. Logistic regression was used to explore interactions among race, ethnicity, rurality, and neighborhood disadvantage, controlling for sociodemographic characteristics, comorbidities, and ulcer severity. RESULTS The cohort included 124 487 patients, with a mean (SD) age of 71.5 (13.0) years, of whom 71 286 (57.3%) were men, 13 100 (10.5%) were rural, and 21 649 (17.4%) identified as Black. Overall, 17.6% of the cohort (n = 21 919), 18.3% of rural patients (2402 of 13 100), and 21.9% of patients identifying as Black (4732 of 21 649) underwent major leg amputation or died. Among 1239 rural patients identifying as Black, this proportion was 28.0% (n = 347). This proportion exceeded the expected excess for rural patients (18.3% - 17.6% = 0.7%) plus those identifying as Black (21.9% - 17.6% = 4.3%) by more than 2-fold (28.0% - 17.6% = 10.4% vs 0.7% + 4.3% = 5.0%). The adjusted predicted probability of major leg amputation or death remained high at 24.7% (95% CI, 22.4%-26.9%), with a significant interaction between race and rurality. CONCLUSIONS AND RELEVANCE Rural patients identifying as Black had a more than 10% absolute increased risk of major leg amputation or death compared with the overall cohort. This study suggests that racial and rural disparities interacted, amplifying risk. Findings support using an intersectionality lens to investigate and address disparities in major leg amputation and mortality for patients with diabetic foot ulcers.
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Affiliation(s)
| | - W. Ryan Powell
- Department of Medicine, University of Wisconsin, Madison
| | - Farah Kaiksow
- Department of Medicine, University of Wisconsin, Madison
| | - Joseph Kramer
- Department of Medicine, University of Wisconsin, Madison
| | - Yao Liu
- Department of Ophthalmology, University of Wisconsin, Madison
| | - Amy J. H. Kind
- Department of Medicine, University of Wisconsin, Madison
- Center for Health Disparities Research, University of Wisconsin School of Medicine and Public Health, Madison
- Geriatric Research Education and Clinical Center (GRECC), William S. Middleton Hospital, Department of Veterans Affairs, Madison, Wisconsin
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17
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Hansmann KJ, Powell WR, Golden BP, Kind AJH. Hospital Characteristics by Proportion of Patients from Disadvantaged Neighborhoods. J Hosp Med 2022; 17:181-185. [PMID: 35418811 PMCID: PMC9000522 DOI: 10.1002/jhm.12793] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Neighborhood disadvantage reflects historic and ongoing systemic injustices. Without addressing these upstream social determinants of health, hospitals may face different risk profiles for important quality metrics. Our objective was to assess differences in hospital characteristics where the proportion of patients residing in severely disadvantaged neighborhoods was high vs low. Using Medicare fee-for-service claims between January 1, 2014 and November 30, 2014 (5,807,499 hospital stays), we calculated Area Disadvantage Share (ADS), the proportion of each hospital's discharges to severely disadvantaged neighborhoods, for 4,528 hospitals. We examined hospital characteristics by distribution of ADS and by risk-adjusted 30-day readmission. Hospitals in the highest decile cared for a higher proportion of Black patients, were more often located in rural areas, and had higher patient risk of 30-day readmission compared to all other deciles. Hospitals face unequal burdens of neighborhood disadvantage, a factor distinct from other social determinants such as rurality.
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Affiliation(s)
- Kellia J Hansmann
- Department of Family Medicine and Community Health, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
| | - W Ryan Powell
- Center for Health Disparities Research, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Blair P Golden
- Division of Hospital Medicine, Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Amy J H Kind
- Center for Health Disparities Research, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
- Division of Geriatrics, Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
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18
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Powell WR, Zuelsdorff M, Chin NA, Buckingham WR, Rissman RA, Bendlin BB, Kind AJ. Geographic proximity, neuropathology and ADRC brain donation. Alzheimers Dement 2021. [DOI: 10.1002/alz.057512] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Affiliation(s)
- W Ryan Powell
- Center for Health Disparities Research, University of Wisconsin School of Medicine and Public Health Madison WI USA
- Health Services and Care Research Program, University of Wisconsin School of Medicine and Public Health Madison WI USA
- Department of Medicine, Geriatrics Division, University of Wisconsin School of Medicine and Public Health Madison WI USA
| | - Megan Zuelsdorff
- Wisconsin Alzheimer's Disease Research Center, University of Wisconsin School of Medicine and Public Health Madison WI USA
- University of Wisconsin‐Madison School of Nursing Madison WI USA
| | - Nathaniel A Chin
- Department of Medicine, Geriatrics Division, University of Wisconsin School of Medicine and Public Health Madison WI USA
- Wisconsin Alzheimer's Disease Research Center, University of Wisconsin School of Medicine and Public Health Madison WI USA
- Wisconsin Alzheimer’s Institute, University of Wisconsin‐Madison School of Medicine and Public Health Madison WI USA
| | - William R Buckingham
- Center for Health Disparities Research, University of Wisconsin School of Medicine and Public Health Madison WI USA
- Health Services and Care Research Program, University of Wisconsin School of Medicine and Public Health Madison WI USA
| | - Robert A Rissman
- Department of Neurosciences, University of California San Diego La Jolla CA USA
- Shiley‐Marcos Alzheimer's Disease Research Center, University of California San Diego La Jolla CA USA
| | - Barbara B Bendlin
- Department of Medicine, Geriatrics Division, University of Wisconsin School of Medicine and Public Health Madison WI USA
- Wisconsin Alzheimer's Disease Research Center, University of Wisconsin School of Medicine and Public Health Madison WI USA
- Wisconsin Alzheimer’s Institute, University of Wisconsin‐Madison School of Medicine and Public Health Madison WI USA
- Geriatric Research Education and Clinical Center, William S. Middleton Hospital, United States Department of Veterans Affairs Madison WI USA
| | - Amy J Kind
- Center for Health Disparities Research, University of Wisconsin School of Medicine and Public Health Madison WI USA
- Health Services and Care Research Program, University of Wisconsin School of Medicine and Public Health Madison WI USA
- Department of Medicine, Geriatrics Division, University of Wisconsin School of Medicine and Public Health Madison WI USA
- Wisconsin Alzheimer's Disease Research Center, University of Wisconsin School of Medicine and Public Health Madison WI USA
- Geriatric Research Education and Clinical Center, William S. Middleton Hospital, United States Department of Veterans Affairs Madison WI USA
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19
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Keller SA, Hansmann KJ, Powell WR, Bendlin BB, Kind AJH. A Scoping Review of the Association of Social Disadvantage and Cerebrovascular Disease Confirmed by Neuroimaging and Neuropathology. Int J Environ Res Public Health 2021; 18:ijerph18137071. [PMID: 34281008 PMCID: PMC8297247 DOI: 10.3390/ijerph18137071] [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] [Subscribe] [Scholar Register] [Received: 06/02/2021] [Revised: 06/25/2021] [Accepted: 06/29/2021] [Indexed: 11/24/2022]
Abstract
Social disadvantage—a state of low-income, limited education, poor living conditions, or limited social support—mediates chronic health conditions, including cerebrovascular disease. Social disadvantage is a key component in several health impact frameworks, providing explanations for how individual-level factors interact with interpersonal and environmental factors to create health disparities. Understanding the association between social disadvantage and vascular neuropathology, brain lesions identified by neuroimaging and autopsy, could provide insight into how one’s social context interacts with biological processes to produce disease. The goal of this scoping review was to evaluate the scientific literature on the relationship between social disadvantage and cerebrovascular disease, confirmed through assessment of vascular neuropathology. We reviewed 4049 titles and abstracts returned from our search and included records for full-text review that evaluated a measure of social disadvantage as an exposure variable and cerebrovascular disease, confirmed through assessment of vascular neuropathology, as an outcome measure. We extracted exposures and outcomes from 20 articles meeting the criteria after full-text review, and described the study findings and populations sampled. An improved understanding of the link between social factors and cerebrovascular disease will be an important step in moving the field closer to addressing the fundamental causes of disease and towards more equitable brain health.
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Affiliation(s)
- Sarah A. Keller
- Department of Population Health Sciences, School of Medicine and Public Health, University of Wisconsin, Madison, WI 53705, USA
- Center for Health Disparities Research, School of Medicine and Public Health, University of Wisconsin, Madison, WI 53705, USA; (W.R.P.); (B.B.B.); (A.J.H.K.)
- Health Services and Care Research Program, Department of Medicine, School of Medicine and Public Health, University of Wisconsin, Madison, WI 53705, USA
- Correspondence:
| | - Kellia J. Hansmann
- Department of Family Medicine and Community Health, School of Medicine and Public Health, University of Wisconsin, Madison, WI 53705, USA;
| | - W. Ryan Powell
- Center for Health Disparities Research, School of Medicine and Public Health, University of Wisconsin, Madison, WI 53705, USA; (W.R.P.); (B.B.B.); (A.J.H.K.)
- Health Services and Care Research Program, Department of Medicine, School of Medicine and Public Health, University of Wisconsin, Madison, WI 53705, USA
- Department of Medicine, Geriatrics Division, School of Medicine and Public Health, University of Wisconsin, Madison, WI 53705, USA
| | - Barbara B. Bendlin
- Center for Health Disparities Research, School of Medicine and Public Health, University of Wisconsin, Madison, WI 53705, USA; (W.R.P.); (B.B.B.); (A.J.H.K.)
- Department of Medicine, Geriatrics Division, School of Medicine and Public Health, University of Wisconsin, Madison, WI 53705, USA
- Wisconsin Alzheimer’s Disease Research Center, School of Medicine and Public Health, University of Wisconsin, Madison, WI 53705, USA
| | - Amy J. H. Kind
- Center for Health Disparities Research, School of Medicine and Public Health, University of Wisconsin, Madison, WI 53705, USA; (W.R.P.); (B.B.B.); (A.J.H.K.)
- Health Services and Care Research Program, Department of Medicine, School of Medicine and Public Health, University of Wisconsin, Madison, WI 53705, USA
- Department of Medicine, Geriatrics Division, School of Medicine and Public Health, University of Wisconsin, Madison, WI 53705, USA
- Wisconsin Alzheimer’s Disease Research Center, School of Medicine and Public Health, University of Wisconsin, Madison, WI 53705, USA
- Geriatric Research Education and Clinical Center (GRECC), William S. Middleton Hospital, United States Department of Veterans Affairs, Madison, WI 53705, USA
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Sheehy AM, Kaiksow F, Powell WR, Bykovskyi AG, Bartels CM, Golden B, Kind AJH. The Hospital Readmissions Reduction Program and Observation Hospitalizations. J Hosp Med 2021; 16:409-411. [PMID: 34197304 PMCID: PMC8248819 DOI: 10.12788/jhm.3634] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [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: 02/11/2021] [Accepted: 04/02/2021] [Indexed: 11/20/2022]
Abstract
The Centers for Medicare & Medicaid Services (CMS) Hospital Readmissions Reduction Program (HRRP) penalizes hospitals having excess inpatient rehospitalizations within 30 days of index inpatient stays for targeted conditions. Observation hospitalizations are increasing in frequency and may clinically resemble inpatient hospitalizations, yet HRRP excludes observation in index and 30-day rehospitalization counts. Using 100% 2014 Medicare fee-for-service claims and CMS's 30-day rehospitalization methodology, we modeled how observation hospitalizations impact HRRP metrics when counted as index (denominator) and 30-day (numerator) rehospitalizations. Of 3,806,772 index hospitalizations for HRRP conditions, 418,923 (11%) were observation; 18% (155,553/876,033) of rehospitalizations were invisible to HRRP due to observation hospitalization as index (34%; 63,740/188,430), 30-day outcome (53%; 100,343/188,430), or both (13%; 24,347/188,430). By ignoring observation hospitalizations as index and 30-day events, nearly one of five HRRP rehospitalizations is missed. Policymakers might consider this an opportunity to address broad challenges of the two-tiered observation and inpatient hospital billing distinction.
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Affiliation(s)
- Ann M Sheehy
- Health Services and Care Research Program, University of Wisconsin Department of Medicine, Madison, Wisconsin
- Center for Health Disparities Research, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
- Department of Medicine, Division of Hospital Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
- Corresponding Author: Ann M Sheehy, MD, MS; ; Telephone: 608-261-1571; Twitter: @SheehyAnn
| | - Farah Kaiksow
- Health Services and Care Research Program, University of Wisconsin Department of Medicine, Madison, Wisconsin
- Department of Medicine, Division of Hospital Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - W Ryan Powell
- Health Services and Care Research Program, University of Wisconsin Department of Medicine, Madison, Wisconsin
- Center for Health Disparities Research, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
- Department of Medicine, Division of Geriatrics and Gerontology, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Andrea Gilmore Bykovskyi
- Health Services and Care Research Program, University of Wisconsin Department of Medicine, Madison, Wisconsin
- Center for Health Disparities Research, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
- School of Nursing, University of Wisconsin, Madison, Wisconsin
| | - Christie M Bartels
- Health Services and Care Research Program, University of Wisconsin Department of Medicine, Madison, Wisconsin
- Department of Medicine, Division of Rheumatology, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Blair Golden
- Health Services and Care Research Program, University of Wisconsin Department of Medicine, Madison, Wisconsin
- Department of Medicine, Division of Hospital Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Amy JH Kind
- Health Services and Care Research Program, University of Wisconsin Department of Medicine, Madison, Wisconsin
- Center for Health Disparities Research, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
- Department of Medicine, Division of Geriatrics and Gerontology, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
- Department of Veterans Affairs Geriatrics Research Education and Clinical Center, Madison, Wisconsin
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21
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Bartels CM, Chodara A, Chen Y, Wang X, Powell WR, Shi F, Schletzbaum M, Sheehy AM, Kaiksow FA, Gilmore-Bykovskyi AL, Garg S, Yu M, Kind AJ. One Quarter of Medicare Hospitalizations in Patients with Systemic Lupus Erythematosus Readmitted within Thirty Days. Semin Arthritis Rheum 2021; 51:477-485. [PMID: 33813261 DOI: 10.1016/j.semarthrit.2021.02.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [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: 11/02/2020] [Revised: 01/09/2021] [Accepted: 02/15/2021] [Indexed: 01/23/2023]
Abstract
OBJECTIVE Thirty-day hospital readmissions in systemic lupus erythematosus (SLE) approach proportions in Medicare-reported conditions including heart failure (HF). We compared adjusted 30-day readmission and mortality among SLE, HF, and general Medicare to assess predictors informing readmission prevention. METHODS This database study used a 20% sample of all US Medicare 2014 adult hospitalizations to compare risk of 30-day readmission and mortality among admissions with SLE, HF, and neither per discharge diagnoses (if both SLE and HF, classified as SLE). Inclusion required live discharge and ≥12 months of Medicare A/B before admission to assess baseline covariates including patient, geographic, and hospital factors. Analysis used observed and predicted probabilities, and multivariable GEE models clustered by patient to report adjusted risk ratios (ARRs) of 30-day readmission and mortality. RESULTS SLE admissions (n=10,868) were younger, predominantly female, more likely to be Black, disabled, and have Medicaid or end-stage renal disease (ESRD). Observed 30-day readmissions of 24% were identical for SLE and HF (p = 0.6), and higher than other Medicare (16%, p < 0.001). Both SLE and HF had elevated readmission risk (ARR 1.08, (95% CI (1.04, 1.13)); 1.11, (1.09, 1.13)). SLE readmissions were higher for Black (30%) versus White (21%) populations, and highest in ages 18-33 (39%) and ESRD (37%). Admissions of Black patients with SLE from least disadvantaged neighborhoods had highest 30-day mortality (9% versus 3% White). CONCLUSION Thirty-day SLE readmissions rivaled HF at 24%. Readmission prevention programs should engage young, ESRD patients with SLE and examine potential causal gaps in SLE care and transitions.
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Affiliation(s)
- Christie M Bartels
- University of Wisconsin School of Medicine and Public Health, Department of Medicine, Rheumatology Division, Madison, WI, USA; University of Wisconsin School of Medicine and Public Health, Department of Medicine, Health Services & Care Research Program, Madison, WI, USA.
| | - Ann Chodara
- University of Wisconsin School of Medicine and Public Health, Department of Medicine, Rheumatology Division, Madison, WI, USA; University of Wisconsin Hospital and Clinics, Madison, WI, USA
| | - Yi Chen
- University of Wisconsin School of Medicine and Public Health, Department of Biostatistics and Medical Informatics, Madison, WI, USA
| | - Xing Wang
- University of Wisconsin School of Medicine and Public Health, Department of Biostatistics and Medical Informatics, Madison, WI, USA
| | - W Ryan Powell
- University of Wisconsin School of Medicine and Public Health, Department of Medicine, Geriatrics Division, Madison, WI, USA; University of Wisconsin School of Medicine and Public Health, Department of Medicine, Health Services & Care Research Program, Madison, WI, USA
| | - Fangfang Shi
- University of Wisconsin School of Medicine and Public Health, Department of Medicine, Geriatrics Division, Madison, WI, USA; University of Wisconsin School of Medicine and Public Health, Department of Medicine, Health Services & Care Research Program, Madison, WI, USA
| | - Maria Schletzbaum
- University of Wisconsin School of Medicine and Public Health, Department of Population Health Sciences, Madison, WI, USA
| | - Ann M Sheehy
- University of Wisconsin School of Medicine and Public Health, Department of Medicine, Health Services & Care Research Program, Madison, WI, USA; University of Wisconsin School of Medicine and Public Health, Department of Medicine, Hospital Medicine Division, Madison, WI, USA
| | - Farah A Kaiksow
- University of Wisconsin School of Medicine and Public Health, Department of Medicine, Health Services & Care Research Program, Madison, WI, USA; University of Wisconsin School of Medicine and Public Health, Department of Medicine, Hospital Medicine Division, Madison, WI, USA
| | - Andrea L Gilmore-Bykovskyi
- University of Wisconsin School of Medicine and Public Health, Department of Medicine, Geriatrics Division, Madison, WI, USA; University of Wisconsin School of Medicine and Public Health, Department of Medicine, Health Services & Care Research Program, Madison, WI, USA; University of Wisconsin-Madison, School of Nursing, Madison, WI, USA
| | - Shivani Garg
- University of Wisconsin School of Medicine and Public Health, Department of Medicine, Rheumatology Division, Madison, WI, USA
| | - Menggang Yu
- University of Wisconsin School of Medicine and Public Health, Department of Biostatistics and Medical Informatics, Madison, WI, USA
| | - Amy J Kind
- University of Wisconsin School of Medicine and Public Health, Department of Medicine, Geriatrics Division, Madison, WI, USA; University of Wisconsin School of Medicine and Public Health, Department of Medicine, Health Services & Care Research Program, Madison, WI, USA; VA Geriatrics Research Education and Clinical Center, William S Middleton VA Hospital, Madison, WI, USA
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22
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Sheehy AM, Powell WR, Kaiksow FA, Buckingham WR, Bartels CM, Birstler J, Yu M, Bykovskyi AG, Shi F, Kind AJH. Thirty-Day Re-observation, Chronic Re-observation, and Neighborhood Disadvantage. Mayo Clin Proc 2020; 95:2644-2654. [PMID: 33276837 PMCID: PMC7720926 DOI: 10.1016/j.mayocp.2020.06.059] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [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: 03/18/2020] [Revised: 05/28/2020] [Accepted: 06/25/2020] [Indexed: 10/22/2022]
Abstract
OBJECTIVE To determine whether neighborhood socioeconomic disadvantage, as determined by the Area Deprivation Index, increases 30-day hospital re-observation risk. PARTICIPANTS AND METHODS This retrospective study of 20% Medicare fee-for-service beneficiary observation stays from January 1, 2014, to November 30, 2014, included 319,980 stays among 273,308 beneficiaries. We evaluated risk for a 30-day re-observation following an index observation stay for those living in the 15% most disadvantaged compared with the 85% least disadvantaged neighborhoods. RESULTS Overall, 4.5% (270,600 of 6,080,664) of beneficiaries had index observation stays, which varied by disadvantage (4.3% [232,568 of 5,398,311] in the least disadvantaged 85% compared with 5.6% [38,032 of 682,353] in the most disadvantaged 15%). Patients in the most disadvantaged neighborhoods had a higher 30-day re-observation rate (2857 of 41,975; 6.8%) compared with least disadvantaged neighborhoods (13,543 of 278,005; 4.9%); a 43% increased risk (unadjusted odds ratio [OR], 1.43; 95% CI, 1.31 to 1.55). After adjustment, this risk remained (adjusted OR, 1.13; 95% CI, 1.04 to 1.22). Discharge to a skilled nursing facility reduced 30-day re-observation risk (OR, 0.63; 95% CI, 0.57 to 0.69), whereas index observation length of stay of 4 or more days (3 midnights) conferred increased risk (OR, 1.29; 95% CI, 1.09 to 1.52); those living in disadvantaged neighborhoods were less likely to discharge to skilled nursing facilities and more likely to have long index stays. Beneficiaries with more than one 30-day re-observation (chronic re-observation) had progressively greater disadvantage by number of stays (adjusted incident rate ratio, 1.08; 95% CI, 1.02 to 1.14). Observation prevalence varied nationally. CONCLUSION Thirty-day re-observation, especially chronic re-observation, is highly associated with socioeconomic neighborhood disadvantage, even after accounting for factors such as race, disability, and Medicaid eligibility. Beneficiaries least able to pay are potentially most vulnerable to costs from serial re-observations and challenges of Medicare observation policy, which may discourage patients from seeking necessary care.
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Affiliation(s)
- Ann M Sheehy
- Health Services and Care Research Program, Department of Medicine, University of Wisconsin, Madison, WI.
| | - W Ryan Powell
- Health Services and Care Research Program, Department of Medicine, University of Wisconsin, Madison, WI; Divisions of Geriatrics and Gerontology, Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI
| | - Farah A Kaiksow
- Health Services and Care Research Program, Department of Medicine, University of Wisconsin, Madison, WI; Hospital Medicine, Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI
| | - William R Buckingham
- Health Services and Care Research Program, Department of Medicine, University of Wisconsin, Madison, WI; Applied Population Laboratory, University of Wisconsin, Madison, WI
| | - Christie M Bartels
- Health Services and Care Research Program, Department of Medicine, University of Wisconsin, Madison, WI; Division of Rheumatology, Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI
| | - Jen Birstler
- Department of Biostatistics & Medical Informatics, University of Wisconsin, Madison, WI
| | - Menggang Yu
- Department of Biostatistics & Medical Informatics, University of Wisconsin, Madison, WI
| | - Andrea Gilmore Bykovskyi
- Health Services and Care Research Program, Department of Medicine, University of Wisconsin, Madison, WI; School of Nursing, University of Wisconsin, Madison, WI
| | - Fangfang Shi
- Health Services and Care Research Program, Department of Medicine, University of Wisconsin, Madison, WI; Divisions of Geriatrics and Gerontology, Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI
| | - Amy J H Kind
- Health Services and Care Research Program, Department of Medicine, University of Wisconsin, Madison, WI; Divisions of Geriatrics and Gerontology, Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI; Department of Veterans Affairs Geriatrics Research Education and Clinical Center, Madison, WI
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Scaria E, Powell WR, Birstler J, Alagoz O, Shirley D, Kind AJH, Safdar N. Neighborhood disadvantage and 30-day readmission risk following Clostridioides difficile infection hospitalization. BMC Infect Dis 2020; 20:762. [PMID: 33066737 PMCID: PMC7565791 DOI: 10.1186/s12879-020-05481-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2020] [Accepted: 10/06/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Clostridioides difficile infection (CDI) is commonly associated with outcomes like recurrence and readmission. The effect of social determinants of health, such as 'neighborhood' socioeconomic disadvantage, on a CDI patient's health outcomes is unclear. Living in a disadvantaged neighborhood could interfere with a CDI patient's ability to follow post-discharge care recommendations and the success probability of these recommendations, thereby increasing risk of readmission. We hypothesized that neighborhood disadvantage was associated with 30-day readmission risk in Medicare patients with CDI. METHODS In this retrospective cohort study, odds of 30-day readmission for CDI patients are evaluated controlling for patient sociodemographics, comorbidities, and hospital and stay-level variables. The cohort was created from a random 20% national sample of Medicare patients during the first 11 months of 2014. RESULTS From the cohort of 19,490 patients (39% male; 80% white; 83% 65 years or older), 22% were readmitted within 30 days of an index stay. Unadjusted analyses showed that patients from the most disadvantaged neighborhoods were readmitted at a higher rate than those from less disadvantaged neighborhoods (26% vs. 21% rate: unadjusted OR = 1.32 [1.20, 1.45]). This relationship held in adjusted analyses, in which residence in the most disadvantaged neighborhoods was associated with 16% increased odds of readmission (adjusted OR = 1.16 [1.04, 1.28]). CONCLUSIONS Residence in disadvantaged neighborhoods poses a significantly increased risk of readmission in CDI patients. Further research should focus on in-depth assessments of this population to better understand the mechanisms underlying these risks and if these findings apply to other infectious diseases.
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Affiliation(s)
- Elizabeth Scaria
- Department of Industrial and Systems Engineering, University of Wisconsin-Madison, 1513 University Avenue, Madison, WI, 53706, USA
| | - W Ryan Powell
- Division of Geriatrics and Gerontology, Department of Medicine, University of Wisconsin-Madison, School of Medicine and Public Health, 1685 Highland Avenue, 5158 Medical Foundation Centennial Building, Madison, WI, 53705, USA
| | - Jen Birstler
- Department of Biostatics & Medical Informatics, University of Wisconsin-Madison, School of Medicine and Public Health, 201 WARF Building, 610 Walnut Street, Madison, WI, 53726, USA
| | - Oguzhan Alagoz
- Department of Industrial and Systems Engineering, University of Wisconsin-Madison, 1513 University Avenue, Madison, WI, 53706, USA.,Department of Population Health Sciences, University of Wisconsin-Madison, School of Medicine and Public Health, 707 WARF Building, 610 Walnut Street, Madison, WI, 53726, USA
| | - Daniel Shirley
- Division of Infectious Diseases, Department of Medicine, University of Wisconsin-Madison, School of Medicine and Public Health, 1685 Highland Avenue, 5158 Medical Foundation Centennial Building, Madison, WI, 53705, USA
| | - Amy J H Kind
- Division of Geriatrics and Gerontology, Department of Medicine, University of Wisconsin-Madison, School of Medicine and Public Health, 1685 Highland Avenue, 5158 Medical Foundation Centennial Building, Madison, WI, 53705, USA.,Geriatric Research Education and Clinical Center, William S. Middleton Memorial Veterans Hospital, 2500 Overlook Terrace, Madison, WI, 53705, USA
| | - Nasia Safdar
- Division of Infectious Diseases, Department of Medicine, University of Wisconsin-Madison, School of Medicine and Public Health, 1685 Highland Avenue, 5158 Medical Foundation Centennial Building, Madison, WI, 53705, USA. .,William S. Middleton Memorial Veterans Hospital, 2500 Overlook Terrace, Madison, WI, 53705, USA.
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Sheehy AM, Locke CFS, Kaiksow FA, Powell WR, Bykovskyi AG, Kind AJH. Improving Healthcare Value: COVID-19 Emergency Regulatory Relief and Implications for Post-Acute Skilled Nursing Facility Care. J Hosp Med 2020; 15:495-497. [PMID: 32804613 PMCID: PMC7518138 DOI: 10.12788/jhm.3482] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2020] [Accepted: 06/02/2020] [Indexed: 11/20/2022]
Abstract
Rarely, if ever, does a national healthcare system experience such rapid and marked change as that seen with the COVID-19 pandemic. In March 2020, the president of the United States declared a national health emergency, enabling the Department of Health & Human Services authority to grant temporary regulatory waivers to facilitate efficient care delivery in a variety of healthcare settings. The statutory requirement that Medicare beneficiaries stay three consecutive inpatient midnights to qualify for post-acute skilled nursing facility coverage is one such waiver. This so-called Three Midnight Rule, dating back to the 1960s as part of the Social Security Act, is being scrutinized more than half a century later given the rise in observation hospital stays. Despite the tragic emergency circumstances prompting waivers, the Centers for Medicare & Medicaid Services and Congress now have a unique opportunity to evaluate potential improvements revealed by COVID-19 regulatory relief and should consider permanent reform of the Three Midnight Rule.
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Affiliation(s)
- Ann M Sheehy
- Division of Hospital Medicine, Department of Medicine, School of Medicine and Public Health, University of Wisconsin, Madison, Wisconsin
- Health Services and Care Research Program, Department of Medicine, School of Medicine and Public Health, University of Wisconsin, Madison, Wisconsin
- Corresponding Author: Ann M Sheehy, MD, MS; . Telephone: 608-262-2434; Twitter: @SheehyAnn
| | - Charles FS Locke
- Department of Care Coordination and Utilization Management, The Johns Hopkins Hospital, Baltimore, Maryland
| | - Farah A Kaiksow
- Division of Hospital Medicine, Department of Medicine, School of Medicine and Public Health, University of Wisconsin, Madison, Wisconsin
- Health Services and Care Research Program, Department of Medicine, School of Medicine and Public Health, University of Wisconsin, Madison, Wisconsin
| | - W Ryan Powell
- Health Services and Care Research Program, Department of Medicine, School of Medicine and Public Health, University of Wisconsin, Madison, Wisconsin
- Division of Geriatrics and Gerontology, Department of Medicine, School of Medicine and Public Health, University of Wisconsin, Madison, Wisconsin
| | - Andrea Gilmore Bykovskyi
- Health Services and Care Research Program, Department of Medicine, School of Medicine and Public Health, University of Wisconsin, Madison, Wisconsin
- School of Nursing, University of Wisconsin, Madison, Wisconsin
| | - Amy JH Kind
- Health Services and Care Research Program, Department of Medicine, School of Medicine and Public Health, University of Wisconsin, Madison, Wisconsin
- Division of Geriatrics and Gerontology, Department of Medicine, School of Medicine and Public Health, University of Wisconsin, Madison, Wisconsin
- Department of Veterans Affairs Geriatrics Research Education and Clinical Center, Madison, Wisconsin
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Powell WR, Buckingham WR, Larson JL, Vilen L, Yu M, Salamat MS, Bendlin BB, Rissman RA, Kind AJH. Association of Neighborhood-Level Disadvantage With Alzheimer Disease Neuropathology. JAMA Netw Open 2020; 3:e207559. [PMID: 32525547 PMCID: PMC7290421 DOI: 10.1001/jamanetworkopen.2020.7559] [Citation(s) in RCA: 82] [Impact Index Per Article: 20.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
IMPORTANCE Social determinants of health, such as income, education, housing quality, and employment, are associated with disparities in Alzheimer disease and health generally, yet these determinants are rarely incorporated within neuropathology research. OBJECTIVE To establish the feasibility of linking neuropathology data to social determinants of health exposures using neighborhood disadvantage metrics (the validated Area Deprivation Index) and to evaluate the association between neighborhood disadvantage and Alzheimer disease-related neuropathology. DESIGN, SETTING, AND PARTICIPANTS This cross-sectional study consisted of decedents with a known home address who donated their brains to 1 of 2 Alzheimer disease research center brain banks in California and Wisconsin between January 1, 1990, and December 31, 2016. Neither site had preexisting social metrics available for their decedents. Neuropathologic features were obtained from each site for data collected using the standardized Neuropathology Data Set form and from autopsy reports. Data were analyzed from June 7 to October 10, 2019. EXPOSURES Geocoded decedent addresses linked to neighborhood disadvantage as measured by the Area Deprivation Index calculated for the year of death. MAIN OUTCOMES AND MEASURES Presence of Alzheimer disease neuropathology. The association between neighborhood disadvantage and Alzheimer disease neuropathology was evaluated via logistic regression, adjusting for age, sex, and year of death. RESULTS The sample consisted of 447 decedents (249 men [56%]; mean [SD] age, 80.3 [9.5] years; median year of death, 2011) spanning 24 years of donation. Fewer decedents (n = 24 [5.4%]) originated from the top 20% most disadvantaged neighborhood contexts. Increasing neighborhood disadvantage was associated with an 8.1% increase in the odds of Alzheimer disease neuropathology for every decile change on the Area Deprivation Index (adjusted odds ratio, 1.08; 95% CI, 1.07-1.09). As such, living in the most disadvantaged neighborhood decile was associated with a 2.18 increased odds of Alzheimer disease neuropathology (adjusted odds ratio, 2.18; 95% CI, 1.99-2.39). CONCLUSIONS AND RELEVANCE The findings of this cross-sectional study suggest that social determinants of health data can be linked to preexisting autopsy samples as a means to study sociobiological mechanisms involved in neuropathology. This novel technique has the potential to be applied to any brain bank within the United States. To our knowledge, this is the first time Alzheimer disease neuropathology has been associated with neighborhood disadvantage.
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Affiliation(s)
- W. Ryan Powell
- Department of Medicine, Geriatrics Division, University of Wisconsin School of Medicine and Public Health, Madison
- Health Services and Care Research Program, University of Wisconsin School of Medicine and Public Health, Madison
| | - William R. Buckingham
- Department of Medicine, Geriatrics Division, University of Wisconsin School of Medicine and Public Health, Madison
- Health Services and Care Research Program, University of Wisconsin School of Medicine and Public Health, Madison
| | - Jamie L. Larson
- Department of Medicine, Geriatrics Division, University of Wisconsin School of Medicine and Public Health, Madison
- Health Services and Care Research Program, University of Wisconsin School of Medicine and Public Health, Madison
| | - Leigha Vilen
- Department of Medicine, Geriatrics Division, University of Wisconsin School of Medicine and Public Health, Madison
- Health Services and Care Research Program, University of Wisconsin School of Medicine and Public Health, Madison
| | - Menggang Yu
- Department of Biostatistics & Medical Informatics, University of Wisconsin, Madison
| | - M. Shahriar Salamat
- Department of Neurological Surgery, University of Wisconsin School of Medicine and Public Health, Madison
- Department of Pathology and Laboratory Medicine, University of Wisconsin School of Medicine and Public Health, Madison
| | - Barbara B. Bendlin
- Department of Medicine, Geriatrics Division, University of Wisconsin School of Medicine and Public Health, Madison
- Wisconsin Alzheimer’s Disease Research Center, University of Wisconsin School of Medicine and Public Health, Madison
- Geriatric Research Education and Clinical Center (GRECC), William S. Middleton Hospital, United States Department of Veterans Affairs, Madison, Wisconsin
- Wisconsin Alzheimer’s Institute, University of Wisconsin School of Medicine and Public Health, Madison
| | - Robert A. Rissman
- Department of Neurosciences, University of California, San Diego
- Shiley-Marcos Alzheimer's Disease Research Center, University of California, San Diego, La Jolla
| | - Amy J. H. Kind
- Department of Medicine, Geriatrics Division, University of Wisconsin School of Medicine and Public Health, Madison
- Health Services and Care Research Program, University of Wisconsin School of Medicine and Public Health, Madison
- Wisconsin Alzheimer’s Disease Research Center, University of Wisconsin School of Medicine and Public Health, Madison
- Geriatric Research Education and Clinical Center (GRECC), William S. Middleton Hospital, United States Department of Veterans Affairs, Madison, Wisconsin
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Powell WR, Kaiksow FA, Kind AJH, Sheehy AM. What Is an Observation Stay? Evaluating the Use of Hospital Observation Stays in Medicare. J Am Geriatr Soc 2020; 68:1568-1572. [PMID: 32270480 DOI: 10.1111/jgs.16441] [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: 01/29/2020] [Revised: 03/06/2020] [Accepted: 03/09/2020] [Indexed: 11/29/2022]
Abstract
BACKGROUND/OBJECTIVES Observation stays are increasingly common for older adults, yet little is known about the extent to which they are being used as the Centers for Medicare and Medicaid Services (CMS) originally intended for unscheduled or acute problems and whether different types of services are reflected in current billing practices. DESIGN Observational cohort study. SETTING/PARTICIPANTS A total of 867,165 qualifying observation stays identified from 451,408 patients using Medicare fee-for-service claims data from a nationally representative 20% beneficiary sample between January 1, 2014, and November 30, 2014. MEASUREMENTS Using descriptive and multivariable logistic model analytic approaches, we evaluated the patient, stay, and hospital characteristics associated with the most common billing practice for observation stays (charge revenue center 0761 exclusively) vs all other practices. RESULTS Sixty-three percent of observation stays were billed exclusively under the 0761 revenue center and were more likely to be for preplanned chronic conditions consisting of short-term treatments (eg, chemotherapy, radiation therapy, wound care, paracentesis, epidural spinal injection). These stays appeared to be used for recurrent single-day visits, given their strong association with prior visits and a high rate of reobservation (41.4%), with frequent return stays appearing in a 7-day pattern. CONCLUSION Nearly two-thirds of observation stays are billed using only the 0761 revenue code and appear to be for prescheduled, repeated treatments-differing substantially from CMS' explicitly stated purpose as a form of care used while a healthcare provider determines whether a patient presenting for unscheduled or acute conditions requires inpatient hospital admission or can be safely discharged. Guidance is needed from CMS to clarify the appropriate role of observation stays, with discussion as to whether episodic single-day, planned treatment for chronic conditions not originating in the emergency department should be billed as observation stays or placed under another mechanism. Subsequent research is needed to understand how the current use of observation stays impact patient out-of-pocket costs. J Am Geriatr Soc 68:1568-1572, 2020.
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Affiliation(s)
- W Ryan Powell
- Division of Geriatrics and Gerontology, Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin.,Health Services and Care Research Program, Department of Medicine, University of Wisconsin, Madison, Wisconsin
| | - Farah A Kaiksow
- Health Services and Care Research Program, Department of Medicine, University of Wisconsin, Madison, Wisconsin.,Division of Hospital Medicine, Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Amy J H Kind
- Division of Geriatrics and Gerontology, Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin.,Health Services and Care Research Program, Department of Medicine, University of Wisconsin, Madison, Wisconsin.,Department of Veterans Affairs Geriatrics Research Education and Clinical Center, Madison, Wisconsin
| | - Ann M Sheehy
- Health Services and Care Research Program, Department of Medicine, University of Wisconsin, Madison, Wisconsin.,Division of Hospital Medicine, Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
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Kaiksow FA, Powell WR, Ankuda CK, Kind AJH, Jaffery JB, Locke CFS, Sheehy AM. Policy in Clinical Practice: Medicare Advantage and Observation Hospitalizations. J Hosp Med 2020; 15:6-8. [PMID: 31869300 PMCID: PMC6932592 DOI: 10.12788/jhm.3364] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2019] [Accepted: 11/24/2019] [Indexed: 11/20/2022]
Affiliation(s)
- Farah Acher Kaiksow
- Department of Medicine, Division of Hospital Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
- Health Services and Care Research Program, University of Wisconsin Department of Medicine, Madison, Wisconsin
- Corresponding Author: Farah Acher Kaiksow, MD, MPP; E-mail: ; Telephone: 608-265-3518
| | - W Ryan Powell
- Health Services and Care Research Program, University of Wisconsin Department of Medicine, Madison, Wisconsin
- Department of Medicine, Division of Geriatrics and Gerontology, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Claire K Ankuda
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Amy J H Kind
- Health Services and Care Research Program, University of Wisconsin Department of Medicine, Madison, Wisconsin
- Department of Medicine, Division of Geriatrics and Gerontology, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
- Department of Veterans Affairs, Geriatrics Research Education and Clinical Center, Madison, Wisconsin
| | - Jonathan B Jaffery
- Department of Medicine, Division of Nephrology, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Charles F S Locke
- Department of Medicine, Division of General Internal Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Ann M Sheehy
- Health Services and Care Research Program, University of Wisconsin Department of Medicine, Madison, Wisconsin
- Department of Medicine, Division of Hospital Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
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Powell WR, Christiansen CL, Miller DR. Long-term comparative safety analysis of the risks associated with adding or switching to a sulfonylurea as second-line Type 2 diabetes mellitus treatment in a US veteran population. Diabet Med 2019; 36:1384-1390. [PMID: 30343492 DOI: 10.1111/dme.13839] [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] [Accepted: 10/18/2018] [Indexed: 12/01/2022]
Abstract
AIM To examine the risks of all-cause mortality and cardiovascular events associated with adding vs switching to second-line therapies in a comparative safety study of people with Type 2 diabetes mellitus. METHODS We conducted a retrospective cohort study using an as-treated analysis of people served by the Veterans Health Administration who were on metformin and subsequently augmented this treatment or switched to other oral glucose-lowering treatments between 1998 and 2012. This study included 145 250 people with long follow-up. Confounding was addressed through several strategies, involving weighted propensity score models with rich confounder adjustment and strict inclusion criteria, coupled with an incident-user design. RESULTS Second-line use of sulfonylureas was related to higher mortality (hazard ratio 1.39, 95% CI 1.14, 1.70) and cardiovascular risks (hazard ratio 1.19, 95% CI 1.09, 1.30) compared with thiazolidinedione therapy. Differential hazards were associated with discontinuing or not discontinuing metformin; switching to sulfonylurea therapy was associated with a higher risk of all-cause mortality and cardiovascular events compared with all other therapies. Furthermore, add-on sulfonylurea therapy was associated with an elevated risk for both outcomes when compared with thiazolidinedione add-on therapy. CONCLUSIONS The results of the present study may inform decisions on whether to augment or discontinue metformin; when considering the long-term risks, switching to a sulfonylurea appears unfavourable compared with other therapies. Instead, adding a thiazolidinedione to existing metformin therapy appears to be superior to adding or switching to a sulfonylurea.
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Affiliation(s)
- W R Powell
- Center for Healthcare Organization and Implementation Research, Edith Nourse Rogers Memorial Veterans Hospital, Bedford
- Department of Health Law, Policy and Management, Boston University School of Public Health, Boston, MA, USA
| | - C L Christiansen
- Center for Healthcare Organization and Implementation Research, Edith Nourse Rogers Memorial Veterans Hospital, Bedford
- Department of Health Law, Policy and Management, Boston University School of Public Health, Boston, MA, USA
| | - D R Miller
- Center for Healthcare Organization and Implementation Research, Edith Nourse Rogers Memorial Veterans Hospital, Bedford
- Department of Health Law, Policy and Management, Boston University School of Public Health, Boston, MA, USA
- Department of Dermatology, Boston University School of Medicine, Boston, MA, USA
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Powell WR, Christiansen CL, Miller DR. Meta-Analysis of Sulfonylurea Therapy on Long-Term Risk of Mortality and Cardiovascular Events Compared to Other Oral Glucose-Lowering Treatments. Diabetes Ther 2018; 9:1431-1440. [PMID: 29808360 PMCID: PMC6064594 DOI: 10.1007/s13300-018-0443-z] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2018] [Indexed: 11/30/2022] Open
Abstract
INTRODUCTION Among the most pressing clinical decisions in type 2 diabetes treatments are which drugs should be used after metformin is no longer sufficient, and whether sulfonylureas (SUs) should remain as a suitable second-line treatment. In this article we summarize current evidence on the long-term safety risks associated with SU therapy relative to other oral glucose-lowering therapies. METHODS The MEDLINE database and Clinicaltrials.gov were searched for observational and experimental studies comparing the safety of SUs to that of other diabetes medications in people with type 2 diabetes mellitus through December 15, 2015. Studies with at least 1 year of follow-up, which explicitly examined major cardiovascular events or death in patients who showed no evidence of serious conditions at baseline, were selected for inclusion in meta-analyses. RESULTS SU treatment was associated with an elevated risk relative to treatment with metformin (METF), thiazolidinedione (TZD), dipeptidyl peptidase-4 inhibitor (DPP-4), and glucagon-like peptide-1 (GLP-1) agonist classes, either when compared alone (as a monotherapy) or when used in combination with METF. Significant findings were almost entirely derived from nontrial data and not confirmed by smaller, efficacy designed randomized controlled trials whose effects were in the same direction but much more imprecise. CONCLUSION Although much of the evidence is derived and will continue to come from observational studies, the methodological rigor of such studies is questionable. A key challenge for evaluators is the extent to which they should incorporate evidence from study designs that are quasi-experimental.
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Affiliation(s)
- W Ryan Powell
- Center for Healthcare Organization and Implementation Research, Bedford VA Medical Center, Bedford, MA, USA.
- Department of Health Law, Policy and Management, Boston University School of Public Health, Boston, MA, USA.
| | - Cindy L Christiansen
- Center for Healthcare Organization and Implementation Research, Bedford VA Medical Center, Bedford, MA, USA
- Department of Health Law, Policy and Management, Boston University School of Public Health, Boston, MA, USA
| | - Donald R Miller
- Center for Healthcare Organization and Implementation Research, Bedford VA Medical Center, Bedford, MA, USA
- Department of Health Law, Policy and Management, Boston University School of Public Health, Boston, MA, USA
- Department of Dermatology, Boston University School of Medicine, Boston, MA, USA
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Lesch MF, Powell WR, Horrey WJ, Wogalter MS. The use of contextual cues to improve warning symbol comprehension: making the connection for older adults. Ergonomics 2013; 56:1264-1279. [PMID: 23767856 PMCID: PMC3783898 DOI: 10.1080/00140139.2013.802019] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 12/18/2012] [Revised: 04/24/2013] [Indexed: 06/02/2023]
Abstract
UNLABELLED This study teased apart the effects of comprehensibility and complexity on older adults' comprehension of warning symbols by manipulating the relevance of additional information in further refining the meaning of the symbol. Symbols were systematically altered such that increased visual complexity (in the form of contextual cues) resulted in increased comprehensibility. One hundred older adults, aged 50-71 years, were tested on their comprehension of these symbols before and after training. High comprehensibility-complexity symbols were found to be better understood than low- or medium-comprehensibility-complexity symbols and the effectiveness of the contextual cues varied as a function of training. Therefore, the nature of additional detail determines whether increased complexity is detrimental or beneficial to older adults' comprehension - if the additional details provide 'cues to knowledge', older adults' comprehension improves as a result of the increased complexity. However, some cues may require training in order to be effective. PRACTITIONER SUMMARY Research suggests that older adults have greater difficulty in understanding more complex symbols. However, we found that when the complexity of symbols was increased through the addition of contextual cues, older adults' comprehension actually improved. Contextual cues aid older adults in making the connection between the symbol and its referent.
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Affiliation(s)
- Mary F. Lesch
- Center for Behavioral Sciences, Liberty Mutual Research Institute for Safety, Hopkinton, MA, USA
| | - W. Ryan Powell
- Center for Behavioral Sciences, Liberty Mutual Research Institute for Safety, Hopkinton, MA, USA
- Center for Disability Research, Liberty Mutual Research Institute for Safety, Hopkinton, MA, USA
| | - William J. Horrey
- Center for Behavioral Sciences, Liberty Mutual Research Institute for Safety, Hopkinton, MA, USA
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Lesch MF, Horrey WJ, Wogalter MS, Powell WR. Age-related differences in warning symbol comprehension and training effectiveness: effects of familiarity, complexity, and comprehensibility. Ergonomics 2011; 54:879-890. [PMID: 21973000 DOI: 10.1080/00140139.2011.606924] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Abstract
Age-related changes in selective attention, inhibitory efficiency, and the ability to form new associations suggest that older adults may have greater difficulty with more complex and less comprehensible symbols. We examined comprehension of symbols varying in terms of ratings of familiarity, complexity, and comprehensibility, by younger (aged 18-35) and older (aged 55-70) adults. It was found that older adults have greater difficulty than younger adults in comprehending warning symbols and that accident scenario training improves comprehension. Regression analyses indicated that familiarity and comprehensibility were important in determining performance on the pre-training comprehension test by both younger and older adults. However, training eliminated the effects of stimulus characteristics for younger adults, while older adults' comprehension continued to be significantly influenced by comprehensibility. We suggest that symbol design incorporates cues to knowledge to facilitate the linkage between new knowledge (i.e. the warning symbol) and relevant knowledge in long-term memory. Statement of Relevance: Symbol characteristics play an important role in age-related differences in warning symbol comprehension. To optimise comprehension by older adults, symbols should have a clear relationship with areal-world referent. Alternatively, symbol design could incorporate cues to knowledge to facilitate the linkage between new knowledge and relevant knowledge in long-term memory.
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Affiliation(s)
- M F Lesch
- Center for Behavioral Sciences, Liberty Mutual Research Institute for Safety, 71 Frankland Road, Hopkinton, MA 01748, USA.
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Powell WR, Schirillo JA. Hemispheric laterality measured in Rembrandt's portraits using pupil diameter and aesthetic verbal judgements. Cogn Emot 2011; 25:868-85. [DOI: 10.1080/02699931.2010.515709] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Abstract
Studies of facial asymmetry have revealed that the left and the right sides of the face differ in emotional attributes. This paper reviews many of these distinctions to determine how these asymmetries influence portrait paintings. It does so by relating research involving emotional expression to aesthetic pleasantness in portraits. For example, facial expressions are often asymmetrical-the left side of the face is more emotionally expressive and more often connotes negative emotions than the right side. Interestingly, artists tend to expose more of their poser's left cheek than their right. This is significant, in that artists also portray more females than males with their left cheek exposed. Reasons for these psychological findings lead to explanations for the aesthetic leftward bias in portraiture.
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Affiliation(s)
- W R Powell
- Wake Forest University, Winston-Salem, NC 27109, USA
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Powell WR, Adams PR, Cooley DA. Repair of coarctation of the aorta associated with intracardiac repair. Tex Heart Inst J 1983; 10:409-13. [PMID: 15226976 PMCID: PMC344371] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/30/2023]
Affiliation(s)
- W R Powell
- Division of Surgery, Texas Heart Institute of St. Luke's Episcopal Hospital, Houston, Texas 77225, USA
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Abstract
Dose measurements were conducted in a phantom which simulates breast tissue and in another phantom which simulates a breast containing a silicone prosthesis. No detectable difference was found when the irradiations were carried out with tangential beams of 60Co radiation. The degree of backscatter and absorption of radiation by the prosthesis and phantom were also similar. A slight decrease in dose of approximately 8% was found at the interface between the prosthesis and muscle-equivalent material.
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McLaren JR, Olkowski ZL, Powell WR. Application of cytochemical methods for visualization of hypoxic cells in human breast tumors. Panminerva Med 1976; 18:151-5. [PMID: 177925] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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Powell WR. Absorber for solar power. Appl Opt 1974; 13:2430-2435. [PMID: 20134700 DOI: 10.1364/ao.13.002430] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/28/2023]
Abstract
A simple, economical absorber utilizing a new principle of operation to achieve very low reradiation losses while generating temperatures limited by material properties of quartz is described. Its performance is analyzed and indicates approximately 90% thermal efficiency and 73% conversion efficiency for an earth based unit with moderately concentrated (~tenfold) sunlight incident. It is consequently compatible with the most economic of concentrator mirrors (stamped) or mirrors deployable in space. Space applications are particularly attractive, as temperatures significantly below 300 K are possible and permit even higher conversion efficiency.
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Powell WR. Transmission characteristics of specularly reflecting light pipes uniformly irradiated by obliquely inclined rays. Appl Opt 1974; 13:952-954. [PMID: 20126105 DOI: 10.1364/ao.13.000952] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/28/2023]
Abstract
The light-pipe efficiency or fraction of the incident energy transmitted from one end to the other is expressed as a function of the wall reflectivity rho and geometrical parameters. Light pipes with both circular and rectangular cross sections are considered. The analysis includes skew rays and is mathematically exact within the limits of geometrical optics and a constant specular wall reflectivity. The distribution along the light pipe of the average intensity incident upon the walls is also derived.
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Powell WR. Evaluation of nonisothermal semi-infinite cylinder with specularly reflecting walls as a blackbody source. Appl Opt 1974; 13:593-594. [PMID: 20126028 DOI: 10.1364/ao.13.000593] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/28/2023]
Abstract
The fractional deviation from blackbody radiation due to wall emissivity modestly differing from unity and due to the presence of a temperature gradient (dT/dx) at the open end of a specularly reflecting semi-infinite cylinder of diameter D and end temperature T(1) is shown to be [Equation].
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Powell WR. Determination of electron concentrations from two intensity measurements within the h line. Appl Opt 1969; 8:1041-1044. [PMID: 20072370 DOI: 10.1364/ao.8.001041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/28/2023]
Abstract
A method for calculating the electron concentration il dense plasmas containing hydrogen is suggested which utilizes two intensity measurements at separate points within the profile of the H(beta) line. The relative intensity observed by two detectors is expressed as a function of the electron concentration, plasma temperature, and instrumental parameters such as resolution and wavelength separation between measurements. Electron concentrations between 10(15) cm(-3) and 10(17) cm(-3) may be read directly from graphs presented in this article.
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