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Osmundson SS, Kozhimannil KB, Graves AJ, Ecklund AM, Snowden JM. 294: Medicaid payment policy effects on cesarean birth differ by race. Am J Obstet Gynecol 2019. [DOI: 10.1016/j.ajog.2018.11.315] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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2
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Resnick MJ, Graves AJ, Gambrel RJ, Thapa S, Buntin MB, Penson DF. The association between Medicare accountable care organization enrollment and breast, colorectal, and prostate cancer screening. Cancer 2018; 124:4366-4373. [DOI: 10.1002/cncr.31700] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2018] [Revised: 01/28/2018] [Accepted: 02/14/2018] [Indexed: 11/06/2022]
Affiliation(s)
- Matthew J. Resnick
- Department of Urologic Surgery; Vanderbilt University Medical Center; Nashville Tennessee
- Department of Health Policy; Vanderbilt University Medical Center; Nashville Tennessee
- Geriatric Research and Education Center; Tennessee Valley Veterans Affairs Health Care System; Nashville Tennessee
| | - Amy J. Graves
- Department of Urologic Surgery; Vanderbilt University Medical Center; Nashville Tennessee
| | - Robert J. Gambrel
- Department of Health Policy; Vanderbilt University Medical Center; Nashville Tennessee
| | - Sunita Thapa
- Department of Health Policy; Vanderbilt University Medical Center; Nashville Tennessee
| | - Melinda B. Buntin
- Department of Health Policy; Vanderbilt University Medical Center; Nashville Tennessee
| | - David F. Penson
- Department of Urologic Surgery; Vanderbilt University Medical Center; Nashville Tennessee
- Department of Health Policy; Vanderbilt University Medical Center; Nashville Tennessee
- Geriatric Research and Education Center; Tennessee Valley Veterans Affairs Health Care System; Nashville Tennessee
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Morgans AK, Penson DF, Graves AJ, Chaudhuri P, Sonnenburg D. Osteoclast inhibitor treatment among men with metastatic castration-resistant prostate cancer. 2018. [PMID: 30984916 PMCID: PMC6457685 DOI: 10.31487/j.cor.2018.03.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Background: National Comprehensive Cancer Network guidelines recommend monthly osteoclast inhibitor treatment (OIT) in men with metastatic castration-resistant prostate cancer (mCRPC) to prevent skeletal related events (SREs). We assessed adherence to guidelines by quantifying treatment for SRE prevention in a population-based cohort of men with mCRPC. Methods: Using Surveillance, Epidemiology, and End Results-Medicare data, we identified men aged >65 with prostate cancer as a primary cause of death during 2006–2010. We assessed OIT during a 12-month period between 15 and 3 months before death and used multivariable negative binomial regression to identify factors associated with treatment. Results: Among 9,634 men who died of prostate cancer, 22% received ≥ 1 OIT, and use increased slightly over time. Men age 75–84 and ≥ 85 were less likely than younger men to be treated (IRR 0.63, 95% CI 0.49–0.78 and IRR 0.34, 95% CI 0.17–0.50, respectively). African American men were less likely than white men to receive OIT (IRR 0.75, 95% CI 0.54–0.95), as were men from areas with lower median income (P=0.014). Compared with men seeing a urologist only, men seeing a medical oncologist and a urologist (IRR 2.52, 95% CI 2.36–2.68) or a medical oncologist alone (IRR 3.82, 95% CI 3.54–4.09) had higher incidence rates of treatment. Conclusions: Fewer than a quarter of American men dying of prostate cancer received recommended treatment to prevent SREs within the final year of their lives, with particularly low rates of treatment among older men, African American men, and those living in areas with low median income. Visits with a medical oncologist were associated with increased use. Further evaluation of these disparities by age, race and socioeconomic status are necessary to identify interventions to reduce them.
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Affiliation(s)
| | - Parul Chaudhuri
- Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Amy J. Graves
- Vanderbilt University Center for Quantitative Sciences and Department of Biostatistics, Nashville, TN
| | | | - Alicia K. Morgans
- Northwestern University Feinberg School of Medicine, Chicago, IL
- Correspondence to: Alicia K Morgans, MD, MPH, Department of Medicine, Division of Hematology/Oncology, Northwestern University School of Medicine, 676, N. St. Clair St. Suite 850, Chicago, IL 60611; Tel: 312-695-6182; Fax: 312-695-6189;
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Marra A, Jackson JC, Ely EW, Graves AJ, Schnelle JF, Dittus RS, Wilson A, Han JH. Focusing on Inattention: The Diagnostic Accuracy of Brief Measures of Inattention for Detecting Delirium. J Hosp Med 2018; 13:551-557. [PMID: 29578552 PMCID: PMC6502509 DOI: 10.12788/jhm.2943] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [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] [Indexed: 12/25/2022]
Abstract
BACKGROUND Delirium is frequently missed in most clinical settings. Brief delirium assessments are needed. OBJECTIVE To determine the diagnostic accuracy of reciting the months of year backwards (MOTYB) from December to July (MOTYB-6) and December to January (MOTYB-12) for delirium as diagnosed by a psychiatrist and to explore the diagnostic accuracies of the following other brief attention tasks: (1) spell the word "LUNCH" backwards, (2) recite the days of the week backwards, (3) 10-letter vigilance "A" task, and (4) 5 picture recognition task. DESIGN Preplanned secondary analysis of a prospective observational study. SETTING Emergency department located within an academic, tertiary care hospital. PARTICIPANTS 234 acutely ill patients who were =65 years old. MEASUREMENTS The inattention tasks were administered by a physician. The reference standard for delirium was a comprehensive psychiatrist assessment using Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision criteria. Sensitivities and specificities were calculated. RESULTS Making any error on the MOTYB-6 task had a sensitivity of 80.0% (95% confidence interval [CI], 60.9%-91.1%) and specificity of 57.1% (95% CI, 50.4%- 63.7%). Making any error on the MOTYB-12 task had a sensitivity of 84.0% (95% CI, 65.4%-93.6%) and specificity of 51.9% (95% CI, 45.2%-58.5%). The best combination of sensitivity and specificity was reciting the days of the week backwards task; if the patient made any error, this was 84.0% (95% CI, 65.4%-93.6%) sensitive and 81.9% (95% CI, 76.1%-86.5%) specific. CONCLUSIONS MOTYB-6 and MOTYB-12 had very good sensitivities but had modest specificities for delirium, limiting their use as a standalone assessment. Reciting the days of the week backwards appeared to have the best combination of sensitivity and specificity for delirium.
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Affiliation(s)
- Annachiara Marra
- Division of Allergy, Pulmonary, and Critical Care Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
- Department of Neurosciences, Reproductive and Odontostomatological Sciences, University of Naples, Federico II, Naples, Italy
| | - James C Jackson
- Division of Allergy, Pulmonary, and Critical Care Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
- Center for Health Services Research, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
- Research Service, Department of Veterans Affairs Medical Center, Tennessee Valley Healthcare System, Nashville, Tennessee, USA
- Geriatric Research, Education and Clinical Center (GRECC) Service, Department of Veterans Affairs Medical Center, Tennessee Valley Healthcare System, Nashville, Tennessee, USA
| | - E Wesley Ely
- Division of Allergy, Pulmonary, and Critical Care Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
- Center for Health Services Research, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
- Research Service, Department of Veterans Affairs Medical Center, Tennessee Valley Healthcare System, Nashville, Tennessee, USA
- Geriatric Research, Education and Clinical Center (GRECC) Service, Department of Veterans Affairs Medical Center, Tennessee Valley Healthcare System, Nashville, Tennessee, USA
- Center for Quality Aging, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Amy J Graves
- Department of Urology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - John F Schnelle
- Research Service, Department of Veterans Affairs Medical Center, Tennessee Valley Healthcare System, Nashville, Tennessee, USA
- Geriatric Research, Education and Clinical Center (GRECC) Service, Department of Veterans Affairs Medical Center, Tennessee Valley Healthcare System, Nashville, Tennessee, USA
- Center for Quality Aging, Vanderbilt University Medical Center, Nashville, Tennessee, USA
- Division of General Internal Medicine and Public Health, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Robert S Dittus
- Center for Health Services Research, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
- Geriatric Research, Education and Clinical Center (GRECC) Service, Department of Veterans Affairs Medical Center, Tennessee Valley Healthcare System, Nashville, Tennessee, USA
- Division of General Internal Medicine and Public Health, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Amanda Wilson
- Department of Psychiatry, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Jin H Han
- Center for Health Services Research, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA.
- Center for Quality Aging, Vanderbilt University Medical Center, Nashville, Tennessee, USA
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
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Resnick MJ, Graves AJ, Thapa S, Gambrel R, Tyson MD, Lee D, Buntin MB, Penson DF. Medicare Accountable Care Organization Enrollment and Appropriateness of Cancer Screening. JAMA Intern Med 2018; 178:648-654. [PMID: 29554179 PMCID: PMC5876897 DOI: 10.1001/jamainternmed.2017.8087] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
IMPORTANCE Despite rapid diffusion of Accountable Care Organizations (ACOs), whether ACO enrollment results in observable changes in cancer screening remains unknown. OBJECTIVE To determine whether Medicare Shared Savings Program (MSSP) ACO enrollment changes the appropriateness of screening for breast, colorectal, and prostate cancers. DESIGN, SETTING, AND PARTICIPANTS For this population-based analysis of Medicare beneficiaries, we used Medicare data from 2007 through 2014 and evaluated changes in screening associated with ACO enrollment using differences-in-differences (DD) analyses. We then performed difference-in-difference-in-differences (DDD) analyses to determine whether observed changes in cancer screening associated with ACO enrollment were different across strata of appropriateness, defined using age (65-74 years vs ≥75 years) and predicted survival (top vs bottom quartile). MAIN OUTCOMES AND MEASURES Rates of breast, colorectal, and prostate cancer screening measured yearly as a proportion of eligible Medicare beneficiaries undergoing relevant screening services. RESULTS Among Medicare beneficiaries, comprising 39 218 652 person-years before MSSP enrollment and 17 252 345 person-years after MSSP enrollment, breast cancer screening declined among both ACO (42.7% precontract, 38.1% postcontract) and non-ACO (37.3% precontract, 34.1% postcontract) populations. The adjusted rate of decline (DD) in the ACO population exceeded the non-ACO population by 0.79% (P < .001). This decline was most pronounced among elderly women (-2.1%), with minimal observed change among younger women (-0.26%). Baseline colorectal cancer screening rates were lower than those for breast cancer among both ACO (10.1% precontract, 10.3% postcontract) and non-ACO (9.2% precontract, 9.1% postcontract) populations. We observed an adjusted 0.24% (P = .03) increase in screening associated with ACO enrollment, most pronounced among younger Medicare beneficiaries (0.36%). For breast and colorectal cancer, we observed statistically significant differences in estimates of effect between age strata, suggesting that the ACO effect on cancer screening is mediated by age (DDD for both P < .001). Prostate cancer screening declined among ACO (35.1% precontract, 28.5% postcontract) and non-ACO (31.2% precontract, 25.7% postcontract) populations. The adjusted rate of decline in the ACO population exceeded that of the non-ACO population by 1.2%. We observed no difference in estimate of effect between age strata, suggesting that the ACO-mediated changes in prostate cancer screening are similar among younger and elderly men. Results characterizing appropriateness with predicted survival mirrored those when stratified by age. CONCLUSIONS AND RELEVANCE Medicare Shared Savings Program ACO enrollment is associated with more appropriate breast and colorectal screening, although the magnitude of the observed ACO effect is modest in the early ACO experience.
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Affiliation(s)
- Matthew J Resnick
- Departments of Urologic Surgery, Vanderbilt University Medical Center, Nashville, Tennessee.,Departments of Health Policy, Vanderbilt University Medical Center, Nashville, Tennessee.,Geriatric Research and Education Center, Tennessee Valley VA Health Care System, Nashville
| | - Amy J Graves
- Departments of Urologic Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Sunita Thapa
- Departments of Health Policy, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Robert Gambrel
- Departments of Health Policy, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Mark D Tyson
- Department of Urology, Mayo Clinic, Scottsdale, Arizona
| | - Daniel Lee
- Departments of Urologic Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Melinda B Buntin
- Departments of Health Policy, Vanderbilt University Medical Center, Nashville, Tennessee
| | - David F Penson
- Departments of Urologic Surgery, Vanderbilt University Medical Center, Nashville, Tennessee.,Departments of Health Policy, Vanderbilt University Medical Center, Nashville, Tennessee.,Geriatric Research and Education Center, Tennessee Valley VA Health Care System, Nashville
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Bachmann JM, Shah AS, Duncan MS, Greevy RA, Graves AJ, Ni S, Ooi HH, Wang TJ, Thomas RJ, Whooley MA, Freiberg MS. Cardiac rehabilitation and readmissions after heart transplantation. J Heart Lung Transplant 2018; 37:467-476. [PMID: 28619383 PMCID: PMC5947994 DOI: 10.1016/j.healun.2017.05.017] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2017] [Revised: 03/27/2017] [Accepted: 05/17/2017] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Exercise-based cardiac rehabilitation (CR) is under-utilized. CR is indicated after heart transplantation, but there are no data regarding CR participation in transplant recipients. We characterized current CR utilization among heart transplant recipients in the United States and the association of CR with 1-year readmissions using the 2013-2014 Medicare files. METHODS The study population included Medicare beneficiaries enrolled due to disability (patients on the transplant list are eligible for disability benefits under Medicare regulations) or age ≥65 years. We identified heart transplant patients by diagnosis codes and cumulative CR sessions occurring within 1 year after the transplant hospitalization. RESULTS There were 2,531 heart transplant patients in the USA in 2013, of whom 595 (24%) received Medicare coverage and were included in the study. CR utilization was low, with 326 patients (55%) participating in CR programs. The Midwest had the highest proportion of transplant recipients initiating CR (68%, p = 0.001). Patients initiating CR attended a mean of 26.7 (standard deviation 13.3) sessions, less than the generally prescribed program of 36 sessions. Transplant recipients age 35 to 49 years were less likely to initiate CR (odds ratio [OR] 0.39, 95% confidence interval [CI] 0.23 to 0.66, p < 0.001) and attended 8.2 fewer sessions (95% CI 3.5 to 12.9, p < 0.001) than patients age ≥65 years. CR participation was associated with a 29% lower 1-year readmission risk (95% CI 13% to 42%, p = 0.001). CONCLUSIONS Only half of cardiac transplant recipients participate in CR, and those who do have a lower 1-year readmission risk. These data invite further study on barriers to CR in this population.
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Affiliation(s)
- Justin M Bachmann
- Division of Cardiovascular Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA.
| | - Ashish S Shah
- Department of Cardiac Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Meredith S Duncan
- Division of Cardiovascular Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Robert A Greevy
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Amy J Graves
- Department of Urologic Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Shenghua Ni
- Institute for Medicine and Public Health, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Henry H Ooi
- Division of Cardiovascular Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Thomas J Wang
- Division of Cardiovascular Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Randal J Thomas
- Department of Cardiovascular Diseases, Mayo Clinic , Rochester, Minnesota, USA
| | - Mary A Whooley
- Measurement Science Quality Enhancement Research Initiative, Department of Veterans Affairs, San Francisco, California, USA
| | - Matthew S Freiberg
- Division of Cardiovascular Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
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Jackson JC, Mozaffarian D, Graves AJ, Brown NJ, Marchioli R, Kiehl AL, Ely EW. Fish Oil Supplementation Does Not Affect Cognitive Outcomes in Cardiac Surgery Patients in the Omega-3 Fatty Acids for Prevention of Post-Operative Atrial Fibrillation (OPERA) Trial. J Nutr 2018; 148:472-479. [PMID: 29546292 PMCID: PMC6454465 DOI: 10.1093/jn/nxx002] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2017] [Accepted: 10/10/2017] [Indexed: 11/13/2022] Open
Abstract
Background Cognitive decline has been reported following cardiac surgery, leading to great interest in interventions to minimize its occurrence. Long-chain n-3 (ω-3) polyunsaturated fatty acids (PUFAs) have been associated with less cognitive decline in observational studies, yet no trials have tested the effects of n-3 PUFAs on cognitive decline after surgery. Objective We sought to determine whether perioperative n-3 PUFA supplementation reduces postoperative cognitive decline in patients postcardiac surgery. Methods The study comprised a randomized, double-blind, placebo-controlled, multicenter, clinical trial conducted on cardiac surgery recipients at 9 tertiary care medical centers across the United States. Patients were randomly assigned to receive fish oil (1-g capsules containing ≥840 mg n-3 PUFAs as ethyl esters) or placebo, with preoperative loading of 8-10 g over 2-5 d followed postoperatively by 2 g/d until hospital discharge or postoperative day 10, whichever came first. Global cognition was assessed using in-person testing over 30 d with the Repeatable Battery for the Assessment of Neuropsychological Status (RBANS) (primary outcome), Mini-Mental State Exam (secondary outcome), and Trails A and B (secondary outcome) tests. All end points were prespecified. Statistical methods were employed, including descriptive statistics, logistic regression, and various sensitivity analyses. Results A total of 320 US patients were enrolled in the Omega-3 Fatty Acids for Prevention of Post-Operative Atrial Fibrillation (OPERA) Cognitive Trial (OCT), a substudy of OPERA. The median age was 62 y (IQR 53, 70 y). No differences in global cognition were observed between placebo and fish oil groups at day 30 (P = 0.32) for the primary outcome, a composite neuropsychological RBANS score. The population demonstrated resolution of initial 4-d cognitive decline back to baseline function by 30 d on the RBANS. Conclusion Perioperative supplementation with n-3 PUFAs in cardiac surgical patients did not influence cognition ≤30 d after discharge. Modern anesthetic, surgical, and postoperative care may be mitigating previously observed long-term declines in cognitive function following cardiac surgery. This trial was registered at clinicaltrials.gov as NCT00970489.
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Affiliation(s)
- James C Jackson
- Department of Medicine, Divisions of Allergy, Pulmonary and Critical Care Medicine,Address correspondence to JCJ (e-mail: )
| | | | | | | | | | - Amy L Kiehl
- Department of Medicine, Divisions of Allergy, Pulmonary and Critical Care Medicine,Department of Center for Health Services Research, Vanderbilt University School of Medicine, Nashville, TN
| | - E Wesley Ely
- Department of Medicine, Divisions of Allergy, Pulmonary and Critical Care Medicine,Department of Center for Health Services Research, Vanderbilt University School of Medicine, Nashville, TN,Geriatric Research Education and Clinical Center (GRECC), Department of Veterans Affairs Medical Center, Tennessee Valley Healthcare System, Nashville, TN
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Lee D, Thapa S, Graves AJ, Buntin M, Penson DF, Resnick MJ. Do accountable care organizations affect race mediated differences in cancer screening? J Clin Oncol 2018. [DOI: 10.1200/jco.2018.36.6_suppl.131] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
131 Background: Accountable care organizations (ACO) reflect a payment innovation aimed to orient incentives to improve quality and reduce waste. The objective of this study was to determine whether ACO enrollment affects racial disparities in cancer screening, and to characterize the impact on the appropriateness of prostate cancer screening in minority populations. Methods: We built a cohort of Medicare beneficiaries from 2007 to 2013 were comprising a cohort of 11,087,056 person-years among ACO beneficiaries and 37,187,979 person-years among non-ACO beneficiaries. A difference-in-difference-in-differences (DDD) approach was utilized to identify the effect of ACO enrollment on cancer screening in racial/ethnic minorities relative to non-Hispanic whites. We then characterized differences in screening appropriateness after ACO enrollment using age (65-74 vs. 75+) and predicted survival (top vs. bottom quartile). Results: ACO enrollment was associated with approximately a 5% reduction in prostate cancer overscreening for white beneficiaries, namely among the elderly and those with unfavorable predicted survival. Compared to white men in the lowest quartile of predicted survival, Asian and Hispanic men with similarly low survival had a 4.8% and 13.0% relative increase in prostate cancer screening associated with ACO enrollment (DDD p = 0.015, p = 0.011, respectively). Prostate cancer overscreening was common among Asian men, with 46% of elderly Asian men attributed to an ACO undergoing cancer screening compared to 28% of elderly white men. Furthermore, ACO enrollment was associated with a 2.7% increase in screening relative to whites (DDD p = 0.0005). Compared to white beneficiaries, black men had consistently lower rates of prostate cancer screening. ACO enrollment did not narrow the disparity of prostate cancer screening between healthier (DDD p = 0.75) or younger (DDD p = 0.27) black and white beneficiaries. Conclusions: This study provides evidence of ACO-mediated increases in low-value screening for prostate cancer among sick and elderly Hispanics and Asians. Furthermore, ACO enrollment did not narrow known disparities in high-value prostate cancer screening among healthier and younger black men.
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Affiliation(s)
| | | | - Amy J Graves
- Vanderbilt University Medical Center, Nashville, TN
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Chen AJ, Graves AJ, Resnick MJ, Richards MR. Does Spending More Get More? Health Care Delivery and Fiscal Implications From a Medicare Fee Bump. J Policy Anal Manage 2018; 37:706-731. [PMID: 30272419] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
While salient features of the Affordable Care Act include insurance expansions and private coverage reforms, various other provisions are embedded within the law. We focus on a temporary 10 percent fee increase for primary care visits supplied to publicly insured (Medicare) beneficiaries. Using administrative and survey data, we assess the price shock's impact on service volume, physician labor supply, and quality of care. Primary care physicians (PCPs) in independent practices demonstrate, at most, a marginal 2 percent increase in new patient visits while horizontally and vertically integrated PCPs show no change. Both PCP organizational types witness declines in established patient visits, on average, but there is marked heterogeneity: established patient visits increase by 1 to 2 percent among PCPs with fewer Medicare claims in the pre-period. The Medicare fee bump did not observably impact other labor supply outcomes and quality of care margins. We estimate that the policy introduced a $1.5 billion transfer from taxpayers to providers during the initiative's first three years.
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O'Neil B, Tyson M, Graves AJ, Barocas DA, Chang SS, Penson DF, Resnick MJ. The influence of provider characteristics and market forces on response to financial incentives. Am J Manag Care 2017; 23:662-667. [PMID: 29182351] [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] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
OBJECTIVES Alternative payment models, such as accountable care organizations, use financial incentives as levers for change to facilitate the transition from volume to value. However, implementation raises concerns about adverse changes in market competition and the resultant physician response. We sought to identify physician characteristics and market-level factors associated with variation in response to financial incentives for cancer care that may ultimately be leveraged in risk-shared payment models. STUDY DESIGN Retrospective cohort study of physicians providing minimally invasive bladder cancer procedures to fee-for-service Medicare beneficiaries. METHODS We examined the relationship of between-group differences in market-level factors (competition [Herfindahl-Hirschman Index (HHI)] and provider density) and physician-level factors (use of unique billing codes, number of billing codes per patient, and competing financial interest) to responsiveness to financial incentives. RESULTS Incentive-responsive providers had increased odds (odds ratio [OR], 1.19; 95% CI, 1.04-1.35) of practicing in markets with the highest quartile of provider density but not HHI (OR, 0.96; 95% CI, 0.87-1.05). Incentive-responsive providers were more likely to bill in the highest quartile for unique codes (OR, 1.49; 95% CI, 1.32-1.69) and codes per patient (OR, 1.18; 95% CI, 1.11-1.25) and less likely to have a competing financial interest (OR, 0.76; 95% CI, 0.72-0.81). CONCLUSIONS Responsiveness to financial incentives in cancer care is associated with high market provider density, profit-maximizing billing behavior, and lack of competing financial ownership interests. Identifying physicians and markets responsive to financial incentives may ultimately promote the successful implementation of alternative payment models in cancer care.
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Affiliation(s)
- Brock O'Neil
- Huntsman Cancer Institute, University of Utah, 1950 Circle of Hope, N6405, Salt Lake City, UT 84112. E-mail:
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Tyson MD, Graves AJ, O'Neil B, Barocas DA, Chang SS, Penson DF, Resnick MJ. Urologist-Level Correlation in the Use of Observation for Low- and High-Risk Prostate Cancer. JAMA Surg 2017; 152:27-34. [PMID: 27653425 DOI: 10.1001/jamasurg.2016.2907] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Importance The reporting of individual urologist rates of observation for localized prostate cancer may be a valuable performance measure with important downstream implications for patient and payer stakeholder groups. However, few studies have examined the urologist-level variation in the use of observation across all risk strata of prostate cancer. Objectives To measure variation in the use of observation at the urologist level by disease risk strata and to evaluate the association between the urologist-level rates of observation for men with low-risk and high-risk prostate cancer. Design, Setting, and Participants With the use of linked Surveillance, Epidemiology, and End Results (SEER)-Medicare data, a population-based study of men diagnosed with prostate cancer from January 1, 2004, to December 31, 2009, was performed in SEER catchment areas of the United States. A total of 57 639 men with prostate cancer with 1884 diagnosing urologists were identified. Data were analyzed from October 1 to December 31, 2015. Main Outcomes and Measures The main outcome was observation, which is defined as the absence of definitive treatment within 1 year of diagnosis. In each risk stratum, a multivariable mixed-effects model was fit to characterize associations between observation and selected patient characteristics. From these models, the estimated probability of observation was calculated for each urologist within each risk stratum, and the association between the physician-level estimated rates of observation for low-risk and high-risk disease was assessed. Results Among the 57 639 men included in the study, the estimated probability of observation for low-risk disease varied impressively (mean, 27.8%; range, 5.1%-71.2%) at the individual urologist level. Considerably less urologist-level variation was seen in the use of observation for intermediate-risk disease (11.1%; range, 4.8%-31.5%) and high-risk disease (5.8%; range, 3.2%-16.5%). Furthermore, the estimated rates of observation for low- and high-risk disease were correlated at the urologist level (Spearman ρ = 0.17; P < .001). A comparable correlation was likewise observed among urologists with high-volume prostate cancer practices (Spearman ρ = 0.24; P < .001). Conclusions and Relevance Considerable urologist-level variation is seen in the use of observation for men with low-risk prostate cancer. More important, the use of observation for low-risk and high-risk patients with prostate cancer is correlated at the urologist level. This study reveals the strikingly variable use of observation among US urologists and establishes a framework for the use of urologist-level treatment signatures as a quality measure in the emerging value-based health care environment.
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Affiliation(s)
- Mark D Tyson
- Department of Urologic Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Amy J Graves
- Department of Urologic Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Brock O'Neil
- Department of Urologic Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Daniel A Barocas
- Department of Urologic Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Sam S Chang
- Department of Urologic Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - David F Penson
- Department of Urologic Surgery, Vanderbilt University Medical Center, Nashville, Tennessee2Department of Health Policy, Vanderbilt University Medical Center, Nashville, Tennessee3Geriatric Research and Educational Center, Veterans Affairs Tennessee Valley Health Care System, Nashville
| | - Matthew J Resnick
- Department of Urologic Surgery, Vanderbilt University Medical Center, Nashville, Tennessee2Department of Health Policy, Vanderbilt University Medical Center, Nashville, Tennessee3Geriatric Research and Educational Center, Veterans Affairs Tennessee Valley Health Care System, Nashville
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Jarlenski M, Barry CL, Gollust S, Graves AJ, Kennedy-Hendricks A, Kozhimannil K. Polysubstance Use Among US Women of Reproductive Age Who Use Opioids for Nonmedical Reasons. Am J Public Health 2017. [PMID: 28640680 DOI: 10.2105/ajph.2017.303825] [Citation(s) in RCA: 54] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
OBJECTIVES To determine the prevalence and patterns of polysubstance use among US reproductive-aged women who use opioids for nonmedical purposes. METHODS We used the National Survey of Drug Use and Health (2005-2014) data on female respondents aged 18 to 44 years reporting nonmedical opioid use in the past 30 days (unweighted n = 4498). We categorized patterns of polysubstance use in the past 30 days, including cigarettes, binge drinking, and other legal and illicit substances and reported prevalence adjusted for age, race/ethnicity, and educational attainment. RESULTS Of all women with nonmedical opioid use, 11% reported only opioid use. Polysubstance use was highest in non-Hispanic White women and women with lower educational attainment. The most frequently used other substances among women using opioids nonmedically were cigarettes (56.2% smoked > 5 cigarettes per day), binge drinking (49.7%), and marijuana (32.4%). Polysubstance use was similarly prevalent among pregnant women with nonmedical opioid use. CONCLUSIONS Polysubstance use is highly prevalent among US reproductive-aged women reporting nonmedical opioid use. Public Health Implications. Interventions are needed that address concurrent use of multiple substances.
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Affiliation(s)
- Marian Jarlenski
- Marian Jarlenski is with the Department of Health Policy and Management, University of Pittsburgh Graduate School of Public Health, Pittsburgh, PA. Colleen L. Barry and Alene Kennedy-Hendricks are with the Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD. Sarah Gollust, Amy J. Graves, and Katy Kozhimannil are with the Division of Health Policy and Management, University of Minnesota School of Public Health, Minneapolis
| | - Colleen L Barry
- Marian Jarlenski is with the Department of Health Policy and Management, University of Pittsburgh Graduate School of Public Health, Pittsburgh, PA. Colleen L. Barry and Alene Kennedy-Hendricks are with the Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD. Sarah Gollust, Amy J. Graves, and Katy Kozhimannil are with the Division of Health Policy and Management, University of Minnesota School of Public Health, Minneapolis
| | - Sarah Gollust
- Marian Jarlenski is with the Department of Health Policy and Management, University of Pittsburgh Graduate School of Public Health, Pittsburgh, PA. Colleen L. Barry and Alene Kennedy-Hendricks are with the Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD. Sarah Gollust, Amy J. Graves, and Katy Kozhimannil are with the Division of Health Policy and Management, University of Minnesota School of Public Health, Minneapolis
| | - Amy J Graves
- Marian Jarlenski is with the Department of Health Policy and Management, University of Pittsburgh Graduate School of Public Health, Pittsburgh, PA. Colleen L. Barry and Alene Kennedy-Hendricks are with the Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD. Sarah Gollust, Amy J. Graves, and Katy Kozhimannil are with the Division of Health Policy and Management, University of Minnesota School of Public Health, Minneapolis
| | - Alene Kennedy-Hendricks
- Marian Jarlenski is with the Department of Health Policy and Management, University of Pittsburgh Graduate School of Public Health, Pittsburgh, PA. Colleen L. Barry and Alene Kennedy-Hendricks are with the Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD. Sarah Gollust, Amy J. Graves, and Katy Kozhimannil are with the Division of Health Policy and Management, University of Minnesota School of Public Health, Minneapolis
| | - Katy Kozhimannil
- Marian Jarlenski is with the Department of Health Policy and Management, University of Pittsburgh Graduate School of Public Health, Pittsburgh, PA. Colleen L. Barry and Alene Kennedy-Hendricks are with the Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD. Sarah Gollust, Amy J. Graves, and Katy Kozhimannil are with the Division of Health Policy and Management, University of Minnesota School of Public Health, Minneapolis
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Lee DJ, Mallin K, Graves AJ, Chang SS, Penson DF, Resnick MJ, Barocas DA. Recent Changes in Prostate Cancer Screening Practices and Epidemiology. J Urol 2017; 198:1230-1240. [PMID: 28552708 DOI: 10.1016/j.juro.2017.05.074] [Citation(s) in RCA: 66] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/18/2017] [Indexed: 12/14/2022]
Abstract
PURPOSE Prostate specific antigen based screening for prostate cancer has had a significant impact on the epidemiology of the disease. Its use has been associated with a significant decrease in prostate cancer mortality but has also resulted in the over diagnosis and overtreatment of indolent prostate cancer, exposing many men to the harms of treatment without benefit. The USPSTF (U.S. Preventive Services Task Force) in 2008 issued a recommendation against screening men older than 75 years, and in 2012 against routine screening for all men, indicating that in its interpretation the harms of screening outweigh the benefits. We review changes in the use of prostate specific antigen testing, performance of prostate biopsy, incidence of prostate cancer and stage of disease at presentation since 2012. MATERIALS AND METHODS An English language literature search was performed for terms that included "prostate specific antigen," "screening" and "United States Preventive Services Task Force" in various combinations. A total of 26 original studies had been published on the effects of the USPSTF recommendations on prostate specific antigen based screening or prostate cancer incidence in the United States as of December 1, 2016. RESULTS Review of the literature from 2012 through the end of 2016 indicates that there has been a decrease in prostate specific antigen testing and prostate biopsy. As a result, there has been a decline in the incidence of localized prostate cancer, including low, intermediate and high risk disease. The data regarding stage at presentation have yet to mature but there are some early signs of a shift toward higher burden of disease at presentation. CONCLUSIONS These findings raise concern about a reversal of the observed improvement in prostate cancer specific mortality during preceding decades. Alternative screening strategies would 1) incorporate patient preferences by allowing shared decision-making, 2) preserve the survival benefits associated with screening, 3) improve the specificity of screening to reduce unnecessary biopsies and detection of low risk disease, and 4) promote the use of active surveillance for low risk cancers if they are detected.
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Affiliation(s)
- Daniel J Lee
- Department of Urology, Vanderbilt University Medical Center, Nashville, Tennessee.
| | | | - Amy J Graves
- Center for Surgical Quality and Outcomes Research, Nashville, Tennessee
| | - Sam S Chang
- Department of Urology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - David F Penson
- Department of Urology, Vanderbilt University Medical Center, Nashville, Tennessee; Center for Surgical Quality and Outcomes Research, Nashville, Tennessee; Geriatric Research, Education and Clinical Center, VA Tennessee Valley Health Care System, Nashville, Tennessee
| | - Matthew J Resnick
- Department of Urology, Vanderbilt University Medical Center, Nashville, Tennessee; Center for Surgical Quality and Outcomes Research, Nashville, Tennessee; Geriatric Research, Education and Clinical Center, VA Tennessee Valley Health Care System, Nashville, Tennessee
| | - Daniel A Barocas
- Department of Urology, Vanderbilt University Medical Center, Nashville, Tennessee
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Kozhimannil KB, Graves AJ, Jarlenski M, Kennedy-Hendricks A, Gollust S, Barry CL. Non-medical opioid use and sources of opioids among pregnant and non-pregnant reproductive-aged women. Drug Alcohol Depend 2017; 174:201-208. [PMID: 28285727 PMCID: PMC5486870 DOI: 10.1016/j.drugalcdep.2017.01.003] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2016] [Revised: 01/26/2017] [Accepted: 01/31/2017] [Indexed: 11/17/2022]
Abstract
BACKGROUND The morbidity and mortality burden of the US opioid epidemic falls heavily on reproductive-age women. Information on the patterns of and sources for non-medical use of prescription opioids among reproductive age women, including pregnant women, will inform public health and prevention efforts to mitigate the effects of the opioid epidemic. This study characterized non-medical use of prescription opioids among reproductive-age U.S. women, with a focus on pregnancy status. METHODS We used nationally-representative data from the National Survey of Drug Use and Health (2005-2014) to examine non-medical use (NMU) of prescription opioids in the past 30days among females ages 18-44 (N=154,179), distinguishing pregnant women (N=8069). We used multivariable logistic regression to describe reported sources of opioids, including opioids obtained from a doctor, friend or relative, dealer, or other source. RESULTS Nearly 1% of pregnant women and 2.3% of non-pregnant reproductive-age women reported opioid NMU in the past 30days. Forty-six percent of pregnant women identified a doctor as their source compared with 27.6% of non-pregnant women reporting NMU. Pregnant women reported a friend or relative as their source of opioids less frequently than non-pregnant women (53.8% versus 75.0%), and some pregnant and non-pregnant women acquired opioids from a dealer (14.6% and 10.6%). CONCLUSION Opioid NMU among reproductive-age women is a complex public health challenge affecting a vulnerable population. Pregnant women were more likely than non-pregnant women to list a doctor as their source of opioids for NMU, suggesting the need for targeted policies to address physician prescribing during pregnancy.
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Affiliation(s)
- Katy B Kozhimannil
- Division of Health Policy and Management,University of Minnesota School of Public Health, 420 Delaware St. SE, MMC 729, Minneapolis, MN 55455, United States.
| | - Amy J Graves
- Division of Health Policy and Management,University of Minnesota School of Public Health, 420 Delaware St. SE, MMC 729, Minneapolis, MN 55455, United States.
| | - Marian Jarlenski
- Department of Health Policy and Management, University of Pittsburgh Graduate School of Public Health, 130 DeSoto St., A619, Pittsburgh, PA 15261, United States.
| | - Alene Kennedy-Hendricks
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, 624 N. Broadway, Room 311, Baltimore, MD 21205, United States.
| | - Sarah Gollust
- Division of Health Policy and Management,University of Minnesota School of Public Health, 420 Delaware St. SE, MMC 729, Minneapolis, MN 55455, United States.
| | - Colleen L Barry
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, 624 N. Broadway, Room 311, Baltimore, MD 21205, United States.
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Kozhimannil KB, Graves AJ, Levy R, Patrick SW. Nonmedical Use of Prescription Opioids among Pregnant U.S. Women. Womens Health Issues 2017; 27:308-315. [PMID: 28408072 DOI: 10.1016/j.whi.2017.03.001] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2016] [Revised: 02/23/2017] [Accepted: 03/01/2017] [Indexed: 01/06/2023]
Abstract
OBJECTIVES Nonmedical use of opioids during pregnancy is associated with adverse outcomes for women and infants, making it a prominent target for prevention and identification. Using a nationally representative sample, we determined characteristics of U.S. pregnant women who reported prescription opioid misuse in the past year or during the past month. METHODS We used data from the National Survey on Drug Use and Health (2005-2014) in a retrospective analysis. The sample included 8,721 (weighted n = 23,855,041) noninstitutionalized women, ages 12 to 44, who reported being pregnant when surveyed. Outcomes were nonmedical use of prescription opioid medications during the past 12 months and during the past 30 days. Multivariable logistic regression models were created to determine correlates of nonmedical opioid use after accounting for potential confounding variables. RESULTS Among pregnant women in the United States, 5.1% reported nonmedical opioid use in the past year. In adjusted models, depression or anxiety in the past year was strongly associated with past year nonmedical use (adjusted odd ratio [AOR], 2.15; 95% CI, 1.52-3.04), as were past year use of alcohol (AOR, 1.56; 95% CI, 1.11-2.17), tobacco (AOR, 1.72; 95% CI, 1.17-2.53), and marijuana (AOR, 3.44; 95% CI, 2.47-4.81). Additionally, 0.9% of U.S. pregnant women reported nonmedical opioid use in the past month. Past year depression or anxiety and past month use of alcohol, tobacco, and marijuana each independently predicted past month nonmedical use. CONCLUSIONS Characteristics associated with nonmedical opioid use by pregnant women reveal populations with mental illness and co-occurring substance use. Policy and prevention efforts to improve screening and treatment could focus on the at-risk populations identified in this study.
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Affiliation(s)
- Katy B Kozhimannil
- Division of Health Policy and Management, University of Minnesota School of Public Health, Minneapolis, Minnesota.
| | - Amy J Graves
- Division of Health Policy and Management, University of Minnesota School of Public Health, Minneapolis, Minnesota
| | - Robert Levy
- Department of Family Medicine and Community Health, University of Minnesota Medical School, Minneapolis, Minnesota
| | - Stephen W Patrick
- Department of Pediatrics, Vanderbilt University School of Medicine, Nashville, Tennessee; Department of Health Policy, Vanderbilt Center for Health Services Research, Vanderbilt University School of Medicine, Nashville, Tennessee
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Abstract
OBJECTIVE To calculate physician concentration levels for all U.S. markets using detailed data on integration and accountable care organization (ACO) participation. DATA SOURCE 2015 SK&A office-based physician survey linked to all commercial and public payer ACOs. STUDY DESIGN We construct three separate Herfindahl-Hirschman Index (HHI) measures and plot their distributions. We then investigate how prevailing levels of concentration change when incorporating more detailed organizational features into the HHI measure. PRINCIPAL FINDINGS Horizontal and vertical integration strongly influences measures of physician concentration; however, ACOs have limited impact overall. ACOs are often present in competitive markets, and only in a minority of these markets do ACOs substantively increase physician concentration. CONCLUSIONS Monitoring ACO effects on physician competition will likely have to proceed on a case-by-case basis.
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Affiliation(s)
- Michael R Richards
- Department of Health Policy, School of Medicine, Vanderbilt University, Nashville, TN
| | - Catherine T Smith
- Department of Health Policy, School of Medicine, Vanderbilt University, Nashville, TN
| | - Amy J Graves
- Department of Urologic Surgery, School of Medicine, Vanderbilt University, Nashville, TN
| | - Melinda B Buntin
- Department of Health Policy, School of Medicine, Vanderbilt University, Nashville, TN
| | - Matthew J Resnick
- Departments of Urologic Surgery and Health Policy, Center for Surgical Quality and Outcomes Research, School of Medicine, Vanderbilt University, Nashville, TN.,Geriatric Research and Education Center, Tennessee Valley Veterans Affairs Health Care System, Nashville, TN
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Cohn JA, Ni S, Kaufman MR, Graves AJ, Penson DF, Dmochowski RR, Reynolds WS. Urinary retention and catheter use among U.S. female Medicare beneficiaries: Prevalence and risk factors. Neurourol Urodyn 2017; 36:2101-2108. [PMID: 28267877 DOI: 10.1002/nau.23248] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [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: 08/02/2016] [Accepted: 01/31/2017] [Indexed: 01/12/2023]
Abstract
AIMS To identify the prevalence of and risk factors for urinary retention and catheterization among female Medicare beneficiaries. METHODS We identified women with a diagnosis of urinary retention in a 5% sample of Medicare claims in 2012. Women were categorized into three groups based on the occurrence and duration of urinary catheterization within a 1 year period: 1) no catheterization; 2) short-term catheterization (ie, one or more catheterizations in less than 30 days); and 3) chronic catheterization (catheterizations in multiple 30 day periods within 1 year). We then identified a group of age-matched controls without catheterization or a diagnosis of urinary retention in 2012. Clinical and demographic data were collected for each patient, and risk factors for retention and catheterization were compared across groups. We assessed factors associated with urinary retention using multivariable logistic regression. RESULTS We estimated the rate of retention to be 1532 per 100 000 U.S. female Medicare beneficiaries in 2012, with rates of short term and chronic catheterization estimated to be 160 and 108 per 100 000 women, respectively. Prior diagnoses of neurologic condition, urinary tract infection, and pelvic organ prolapse were positively associated with retention and catheterization in multivariable analyses. CONCLUSIONS We estimated the prevalence of urinary retention diagnoses among female Medicare beneficiaries to be 1532 per 100 000 women. Retention and catheterization were significantly associated with comorbid disease, with the strongest associations identified with a concomitant diagnosis of neurologic condition, UTI, and POP.
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Affiliation(s)
- Joshua A Cohn
- Department of Urologic Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Shenghua Ni
- Department of Urologic Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Melissa R Kaufman
- Department of Urologic Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Amy J Graves
- Department of Urologic Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - David F Penson
- Department of Urologic Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Roger R Dmochowski
- Department of Urologic Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - W Stuart Reynolds
- Department of Urologic Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
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Kolek MJ, Graves AJ, Xu M, Bian A, Teixeira PL, Shoemaker MB, Parvez B, Xu H, Heckbert SR, Ellinor PT, Benjamin EJ, Alonso A, Denny JC, Moons KGM, Shintani AK, Harrell FE, Roden DM, Darbar D. Evaluation of a Prediction Model for the Development of Atrial Fibrillation in a Repository of Electronic Medical Records. JAMA Cardiol 2016; 1:1007-1013. [PMID: 27732699 DOI: 10.1001/jamacardio.2016.3366] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
Importance Atrial fibrillation (AF) contributes to substantial morbidity, mortality, and health care expenditures. Accurate prediction of incident AF would enhance AF management and potentially improve patient outcomes. Objective To validate the AF risk prediction model originally developed by the Cohorts for Heart and Aging Research in Genomic Epidemiology-Atrial Fibrillation (CHARGE-AF) investigators using a large repository of electronic medical records (EMRs). Design, Setting, and Participants In this prediction model study, deidentified EMRs of 33 494 individuals 40 years or older who were white or African American and had no history of AF were reviewed and analyzed. The participants were followed up in the internal medicine outpatient clinics at Vanderbilt University Medical Center for incident AF from December 31, 2005, until December 31, 2010. Adjusting for differences in baseline hazard, the CHARGE-AF Cox proportional hazards model regression coefficients were applied to the EMR cohort. A simple version of the model with no echocardiographic variables was also evaluated. Data were analyzed from October 31, 2013, to January 31, 2014. Main Outcomes and Measures Incident AF. Predictors in the model included age, race, height, weight, systolic and diastolic blood pressure, treatment for hypertension, smoking status, type 2 diabetes, heart failure, history of myocardial infarction, left ventricular hypertrophy, and PR interval. Results Among the 33 494 participants, the median age was 57 (interquartile range, 49-67) years; 57% of patients were women, 43% were men, 85.7% were white, and 14.3% were African American. During the mean (SD) follow-up of 4.8 (0.9) years, 2455 individuals (7.3%) developed AF. Both models had poor calibration in the EMR cohort, with underprediction of AF among low-risk individuals and overprediction of AF among high-risk individuals (10th and 90th percentiles for predicted probability of incident AF, 0.005 and 0.179, respectively). The full CHARGE-AF model had a C index of 0.708 (95% CI, 0.699-0.718) in our cohort. The simple model had similar discrimination (C index, 0.709; 95% CI, 0.699-0.718; P = .70 for difference between models). Conclusions and Relevance Despite reasonable discrimination, the CHARGE-AF models showed poor calibration in this EMR cohort. This study highlights the difficulties of applying a risk model derived from prospective cohort studies to an EMR cohort and suggests that these AF risk prediction models be used with caution in the EMR setting. Future risk models may need to be developed and validated within EMR cohorts.
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Affiliation(s)
- Matthew J Kolek
- Division of Cardiovascular Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Amy J Graves
- Department of Biostatistics, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Meng Xu
- Department of Biostatistics, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Aihua Bian
- Department of Biostatistics, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Pedro Luis Teixeira
- Department of Biomedical Informatics, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - M Benjamin Shoemaker
- Division of Cardiovascular Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Babar Parvez
- Division of Cardiovascular Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Hua Xu
- School of Biomedical Informatics, University of Texas Health Science Center at Houston
| | | | | | - Emelia J Benjamin
- Framingham Heart Study, National Heart Lung and Blood Institute and Boston University, Framingham, Massachusetts8Department of Medicine, Boston University School of Medicine, Boston, Massachusetts
| | - Alvaro Alonso
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Joshua C Denny
- Department of Biomedical Informatics, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Karel G M Moons
- Department of Biostatistics, Vanderbilt University School of Medicine, Nashville, Tennessee10Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, the Netherlands
| | | | - Frank E Harrell
- Department of Biostatistics, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Dan M Roden
- Division of Cardiovascular Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Dawood Darbar
- Division of Cardiovascular Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee12Division of Cardiology, University of Illinois at Chicago
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Brown ET, Osborn D, Mock S, Ni S, Graves AJ, Milam L, Milam D, Kaufman MR, Dmochowski RR, Reynolds WS. Perioperative complications of conduit urinary diversion with concomitant cystectomy for benign indications: A population-based analysis. Neurourol Urodyn 2016; 36:1411-1416. [PMID: 27654310 DOI: 10.1002/nau.23135] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2016] [Accepted: 08/29/2016] [Indexed: 11/09/2022]
Abstract
AIMS Beyond single-institution case series, limited data are available to describe risks of performing a concurrent cystectomy at the time of urinary diversion for benign end-stage lower urinary tract dysfunction. Using a population-representative sample, this study aimed to analyze factors associated with perioperative complications in patients undergoing urinary diversion with or without cystectomy. METHODS A representative sample of patients undergoing urinary diversion for benign indications was identified from the Healthcare Cost and Utilization Project Nationwide Inpatient Sample from 1998 to 2011. Perioperative complications of urinary diversion with and without concomitant cystectomy were identified and coded using the International Classification of Diseases, version 9. Multivariate logistic regression models identified hospital and patient-level characteristics associated with complications of concomitant cystectomy with urinary diversion. RESULTS There were 15,717 records for urinary diversion identified, of which 31.8% demonstrated perioperative complications: urinary diversion with concurrent cystectomy (35.0%) and urinary diversion without concomitant cystectomy (30.6%). Comparing the two groups, a concomitant cystectomy at the time of urinary diversion was significantly associated with a complication (OR = 1.23, 95%CI: 1.03-1.48). Comorbid conditions of obesity, pulmonary circulation disease, drug abuse, weight loss, and electrolyte disorders were positively associated with a complication, while private insurance and southern geographic region were negatively associated. CONCLUSIONS A concomitant cystectomy with urinary diversion for refractory lower urinary tract dysfunction elevates risk in this population-representative sample, particularly in those with certain comorbid conditions. This analysis provides critical information for preoperative patient counseling.
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Affiliation(s)
| | - David Osborn
- Vanderbilt University Medical Center, Nashville, Tennessee
| | - Stephen Mock
- Vanderbilt University Medical Center, Nashville, Tennessee
| | - Shenghua Ni
- Vanderbilt University Medical Center, Nashville, Tennessee
| | - Amy J Graves
- Vanderbilt University Medical Center, Nashville, Tennessee
| | - Laurel Milam
- Vanderbilt University Medical Center, Nashville, Tennessee
| | - Douglas Milam
- Vanderbilt University Medical Center, Nashville, Tennessee
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Sohn W, Graves AJ, Tyson MD, O'Neil B, Chang SS, Ni S, Barocas DA, Penson DF, Resnick MJ. An Empiric Evaluation of the Effect of Variation in Intensity of Followup for Surgically Treated Renal Neoplasms on Cancer Specific Survival. J Urol 2016; 197:37-43. [PMID: 27575607 DOI: 10.1016/j.juro.2016.08.094] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/17/2016] [Indexed: 01/11/2023]
Abstract
PURPOSE Followup protocols after the surgical management of renal cell carcinoma lack clear evidence linking the intensity of imaging surveillance to improved outcomes. In this context we characterized the relationship between surveillance imaging intensity and cancer specific survival. MATERIALS AND METHODS Using SEER-Medicare data we identified 7,603 men with renal cell carcinoma treated surgically between 2004 and 2009. Multivariable negative binomial regression analysis was performed to assess the relationship between patient level characteristics and the variation in imaging intensity. We modeled the association between kidney cancer specific mortality and imaging intensity using Fine and Gray proportional subdistribution hazards regression with other cause death treated as a competing risk for 2 separate followup periods (15 and 36 months). RESULTS More than 40% of patients in the short interval cohort and more than 50% in the intermediate interval group underwent no chest imaging during the evaluated survivorship period. More than 30% of patients in both followup periods had no abdominal imaging tests performed. Overall, followup imaging did not appear to confer an improvement in disease specific survival compared to undergoing no imaging in the 2 survivorship periods. CONCLUSIONS There remains considerable variation in the posttreatment surveillance regimen for patients with renal cell carcinoma in the United States. More importantly, this study raises important questions regarding the link between posttreatment surveillance imaging and survival.
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Affiliation(s)
- William Sohn
- Department of Urologic Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Amy J Graves
- Department of Urologic Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Mark D Tyson
- Department of Urologic Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Brock O'Neil
- Department of Urologic Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Sam S Chang
- Department of Urologic Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Shenghua Ni
- Department of Urologic Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Daniel A Barocas
- Department of Urologic Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - David F Penson
- Department of Urologic Surgery, Vanderbilt University Medical Center, Nashville, Tennessee; Department of Health Policy, Vanderbilt University Medical Center, Nashville, Tennessee; Geriatric Research, Education, and Clinical Center, Tennessee Valley VA Health Care System, Nashville, Tennessee
| | - Matthew J Resnick
- Department of Urologic Surgery, Vanderbilt University Medical Center, Nashville, Tennessee; Department of Health Policy, Vanderbilt University Medical Center, Nashville, Tennessee; Geriatric Research, Education, and Clinical Center, Tennessee Valley VA Health Care System, Nashville, Tennessee.
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Resnick MJ, Graves AJ, Reynolds WS, Barocas DA, Van Horn RL, Buntin MB, Penson DF. Anticipating the Unintended Consequences of Closing the Door on Physician Self-Referral. J Urol 2016; 196:444-50. [DOI: 10.1016/j.juro.2016.01.112] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/03/2016] [Indexed: 11/24/2022]
Affiliation(s)
| | - Amy J. Graves
- Vanderbilt University Medical Center, Nashville, Tennessee
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Brown ET, Osborn D, Mock S, Ni S, Graves AJ, Milam L, Milam D, Kaufman MR, Dmochowski RR, Reynolds WS. Temporal Trends in Conduit Urinary Diversion With Concomitant Cystectomy for Benign Indications: A Population-based Analysis. Urology 2016; 98:70-74. [PMID: 27374730 DOI: 10.1016/j.urology.2016.06.035] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2016] [Revised: 05/31/2016] [Accepted: 06/21/2016] [Indexed: 02/03/2023]
Abstract
OBJECTIVE To describe national trends in cystectomy at the time of urinary diversion for benign indications. Multiple practice patterns exist regarding the necessity for concomitant cystectomy with urinary diversion for benign end-stage lower urinary tract dysfunction. Beyond single-institution reports, limited data are available to describe how concurrent cystectomy is employed on a national level. MATERIALS AND METHODS A representative sample of patients undergoing urinary diversion for benign indications with or without concurrent cystectomy was identified from the Healthcare Cost and Utilization Project Nationwide Inpatient Sample from 1998 to 2011. Using multivariate logistic regression models, we identified hospital- and patient-level characteristics associated with concomitant cystectomy with urinary diversion. RESULTS There was an increase in the proportion of concomitant cystectomy at the time of urinary diversion from 20% to 35% (P < .001) between 1998 and 2011. The increase in simultaneous cystectomy over time occurred at teaching hospitals (vs community hospitals), in older patients, in male patients, in the Medicare population (vs private insurance and Medicaid), and in those with certain diagnoses. CONCLUSION There has been an overall increase in the use of cystectomy at the time of urinary diversion for benign indications on a national level, although the indications driving this clinical decision appear inconsistent.
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Affiliation(s)
| | - David Osborn
- Department of Urologic Surgery, Vanderbilt University Medical Center, Nashville, TN
| | - Stephen Mock
- Department of Urologic Surgery, Vanderbilt University Medical Center, Nashville, TN
| | - Shenghua Ni
- The Institute of Medicine and Public Health, Vanderbilt University Medical Center, Nashville, TN
| | - Amy J Graves
- Department of Urologic Surgery, Vanderbilt University Medical Center, Nashville, TN
| | - Laurel Milam
- Department of Urologic Surgery, Vanderbilt University Medical Center, Nashville, TN
| | - Douglas Milam
- Department of Urologic Surgery, Vanderbilt University Medical Center, Nashville, TN
| | - Melissa R Kaufman
- Department of Urologic Surgery, Vanderbilt University Medical Center, Nashville, TN
| | - Roger R Dmochowski
- Department of Urologic Surgery, Vanderbilt University Medical Center, Nashville, TN
| | - W Stuart Reynolds
- Department of Urologic Surgery, Vanderbilt University Medical Center, Nashville, TN
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Abstract
A new tuberculosis vaccine is needed to replace or enhance BCG, which induces variable protection against Mycobacterium tuberculosis pulmonary infections in adults. Development of new TB vaccine candidates is severely hampered by the lack of a correlate of immunity, unproven animal models, and limited funding opportunities. One candidate, MVA85A, recently failed to meet its efficacy endpoint goals despite promising early-phase trial data. As a result, some in the field believe we should now shift our focus away from product development and toward a research-oriented approach. Here, we outline our suggestions for this research-oriented strategy including diversification of the candidate pipeline, expanding measurements of immunity, improving pre-clinical animal models, and investing in combination pre-clinical/experimental medicine studies. As with any evolution, this change in strategy comes at a cost but may also represent an opportunity for advancing the field.
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Bachmann JM, Shah A, Graves AJ, Ni S, Wang T, Whooley M, Freiberg MS. CARDIAC REHABILITATION IS UNDERUTILIZED AFTER HEART TRANSPLANTATION. J Am Coll Cardiol 2016. [DOI: 10.1016/s0735-1097(16)31857-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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Han JH, Wilson A, Graves AJ, Shintani A, Schnelle JF, Ely EW. A quick and easy delirium assessment for nonphysician research personnel. Am J Emerg Med 2016; 34:1031-6. [PMID: 27021131 DOI: 10.1016/j.ajem.2016.02.069] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2015] [Revised: 01/28/2016] [Accepted: 02/25/2016] [Indexed: 11/28/2022] Open
Abstract
OBJECTIVES Delirium in the emergency department (ED) is an emerging field of research. Most ED research infrastructures utilize lay personnel to collect data, but delirium assessments that can be reliably performed by nonphysicians are lacking. We evaluated the diagnostic performance of the modified Brief Confusion Assessment Method (modified bCAM) for this purpose. METHODS This was a secondary analysis of a prospective observational study that enrolled ED patients 65years or older. The original bCAM was a brief (<2minutes) delirium assessment that assessed for inattention by asking the patient to recite the months backward from December to July. It was modified by adding the Vigilance A ("squeeze my hand when you hear the letter 'A'") to the inattention assessment. The elements of the modified bCAM were performed by a research assistant (RA) and emergency physician. The reference standard for delirium was a psychiatrist assessment performed within 3hours using Diagnostic and Statistical Manual of Mental Disorder, Fourth Edition, Text Revision criteria. All assessors were blinded to each other. Sensitivities and specificities with their 95% confidence intervals (CIs) were calculated for the RA and emergency physician. RESULTS Of the 406 patients enrolled, 50 (12%) were delirious. The modified bCAM was 82.0% (95% CI, 71.4%-92.6%) sensitive and 96.1% (95% CI, 94.0%-98.1%) specific when performed by the RA. The emergency physician's modified bCAM exhibited similar diagnostic performance. CONCLUSIONS The modified bCAM may be a feasible and accurate method for nonphysicians to assess for delirium. Future studies are needed to confirm these findings.
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Affiliation(s)
- Jin H Han
- Center for Quality Aging, Vanderbilt University Medical Center, Nashville, Tennessee; Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, Tennessee; Center for Health Services Research, Vanderbilt University Medical Center, Nashville, Tennessee.
| | - Amanda Wilson
- Department of Psychiatry, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Amy J Graves
- Department of Urologic Society, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Ayumi Shintani
- Department of Clinical Epidemiology and Biostatistics, Osaka University, Osaka, Japan
| | - John F Schnelle
- Center for Quality Aging, Vanderbilt University Medical Center, Nashville, Tennessee; Division of General Internal Medicine and Public Health, Vanderbilt University Medical Center, Nashville, Tennessee; Center for Health Services Research, Vanderbilt University Medical Center, Nashville, Tennessee; Geriatric Research, Education, and Clinical Center, Department of Veterans Affairs Medical Center, Tennessee Valley Health Care Center, Nashville, Tennessee
| | - E Wesley Ely
- Center for Quality Aging, Vanderbilt University Medical Center, Nashville, Tennessee; Center for Health Services Research, Vanderbilt University Medical Center, Nashville, Tennessee; Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, Tennessee; Geriatric Research, Education, and Clinical Center, Department of Veterans Affairs Medical Center, Tennessee Valley Health Care Center, Nashville, Tennessee
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Graves AJ, Kozhimannil KB, Kleinman KP, Wharam JF. The Association between High-Deductible Health Plan Transition and Contraception and Birth Rates. Health Serv Res 2016; 51:187-204. [PMID: 26118959 PMCID: PMC4722206 DOI: 10.1111/1475-6773.12326] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [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] [Indexed: 01/24/2023] Open
Abstract
OBJECTIVE To evaluate the association between employer-mandated enrollment into high-deductible health plans (HDHPs) and contraception and birth rates among reproductive-age women. DATA SOURCES/STUDY SETTING Using data from 2002 to 2008, we examined 1,559 women continuously enrolled in a Massachusetts health plan for 1 year before and after an employer-mandated switch from an HMO to a HDHP, compared with 2,793 matched women contemporaneously enrolled in an HMO. STUDY DESIGN We used an individual-level interrupted time series with comparison series design to examine level and trend changes in clinician-provided contraceptives and a differences-in-differences design to assess annual birth rates. DATA COLLECTION/EXTRACTION METHODS Employer, plan, and member characteristics were obtained from enrollment files. Contraception and childbirth information were extracted from pharmacy and medical claims. PRINCIPAL FINDINGS Monthly contraception rates were 19.0-24.0 percent at baseline. Level and trend changes did not differ between groups (p = .92 and p = .36, respectively). Annual birth rates declined from 57.1/1,000 to 32.7/1,000 among HDHP members and from 61.9/1,000 to 56.2/1,000 among HMO controls, a 40 percent relative reduction in odds of childbirth (odds ratio = 0.60; p = .02). CONCLUSIONS Women who switched to HDHPs experienced a lower birth rate, which might reflect strategies to avoid childbirth-related out-of-pocket costs under HDHPs.
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Affiliation(s)
- Amy J. Graves
- Department of Urologic SurgeryVanderbilt University Medical CenterNashvilleTN
| | - Katy B. Kozhimannil
- Division of Health Policy and ManagementUniversity of Minnesota School of Public HealthMinneapolisMN
| | - Ken P. Kleinman
- Department of Population MedicineHarvard Medical School and Harvard Pilgrim Health Care InstituteBostonMA
| | - J. Frank Wharam
- Department of Population MedicineHarvard Medical School and Harvard Pilgrim Health Care InstituteBostonMA
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Hughes CG, Brummel NE, Girard TD, Graves AJ, Ely EW, Pandharipande PP. Change in endothelial vascular reactivity and acute brain dysfunction during critical illness. Br J Anaesth 2016; 115:794-5. [PMID: 26475809 DOI: 10.1093/bja/aev332] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Renier AC, Morrow JK, Graves AJ, Finno CJ, Howe DK, Owens SD, Tamez-Trevino E, Packham AE, Conrad PA, Pusterla N. Diagnosis of Equine Protozoal Myeloencephalitis Using Indirect Fluorescent Antibody Testing and Enzyme-Linked Immunosorbent Assay Titer Ratios for Sarcocystis neurona and Neospora hughesi. J Equine Vet Sci 2016. [DOI: 10.1016/j.jevs.2015.10.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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O'Neil B, Graves AJ, Barocas DA, Chang SS, Penson DF, Resnick MJ. Doing More for More: Unintended Consequences of Financial Incentives for Oncology Specialty Care. J Natl Cancer Inst 2015; 108:djv331. [PMID: 26582063 DOI: 10.1093/jnci/djv331] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2015] [Accepted: 10/12/2015] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Specialty care remains a significant contributor to health care spending but largely unaddressed in novel payment models aimed at promoting value-based delivery. Bladder cancer, chiefly managed by subspecialists, is among the most costly. In 2005, Centers for Medicare and Medicaid Services (CMS) dramatically increased physician payment for office-based interventions for bladder cancer to shift care from higher cost facilities, but the impact is unknown. This study evaluated the effect of financial incentives on patterns of fee-for-service (FFS) bladder cancer care. METHODS Data from a 5% sample of Medicare beneficiaries from 2001-2013 were evaluated using interrupted time-series analysis with segmented regression. Primary outcomes were the effects of CMS fee modifications on utilization and site of service for procedures associated with the diagnosis and treatment of bladder cancer. Rates of related bladder cancer procedures that were not affected by the fee change were concurrent controls. Finally, the effect of payment changes on both diagnostic yield and need for redundant procedures were studied. All statistical tests were two-sided. RESULTS Utilization of clinic-based procedures increased by 644% (95% confidence interval [CI] = 584% to 704%) after the fee change, but without reciprocal decline in facility-based procedures. Procedures unaffected by the fee incentive remained unchanged throughout the study period. Diagnostic yield decreased by 17.0% (95% CI = 12.7% to 21.3%), and use of redundant office-based procedures increased by 76.0% (95% CI = 59% to 93%). CONCLUSIONS Financial incentives in bladder cancer care have unintended and costly consequences in the current FFS environment. The observed price sensitivity is likely to remain a major issue in novel payment models failing to incorporate procedure-based specialty physicians.
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Affiliation(s)
- Brock O'Neil
- Department of Urologic Surgery, Vanderbilt University, Nashville, TN (BO, AJG, DAB, SSC, DFP, MJR); Geriatric Research Education and Clinical Center, VA Tennessee Valley Healthcare System, Nashville, TN (DFP, MJR).
| | - Amy J Graves
- Department of Urologic Surgery, Vanderbilt University, Nashville, TN (BO, AJG, DAB, SSC, DFP, MJR); Geriatric Research Education and Clinical Center, VA Tennessee Valley Healthcare System, Nashville, TN (DFP, MJR)
| | - Daniel A Barocas
- Department of Urologic Surgery, Vanderbilt University, Nashville, TN (BO, AJG, DAB, SSC, DFP, MJR); Geriatric Research Education and Clinical Center, VA Tennessee Valley Healthcare System, Nashville, TN (DFP, MJR)
| | - Sam S Chang
- Department of Urologic Surgery, Vanderbilt University, Nashville, TN (BO, AJG, DAB, SSC, DFP, MJR); Geriatric Research Education and Clinical Center, VA Tennessee Valley Healthcare System, Nashville, TN (DFP, MJR)
| | - David F Penson
- Department of Urologic Surgery, Vanderbilt University, Nashville, TN (BO, AJG, DAB, SSC, DFP, MJR); Geriatric Research Education and Clinical Center, VA Tennessee Valley Healthcare System, Nashville, TN (DFP, MJR)
| | - Matthew J Resnick
- Department of Urologic Surgery, Vanderbilt University, Nashville, TN (BO, AJG, DAB, SSC, DFP, MJR); Geriatric Research Education and Clinical Center, VA Tennessee Valley Healthcare System, Nashville, TN (DFP, MJR)
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30
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Barocas DA, Mallin K, Graves AJ, Penson DF, Palis B, Winchester DP, Chang SS. Effect of the USPSTF Grade D Recommendation against Screening for Prostate Cancer on Incident Prostate Cancer Diagnoses in the United States. J Urol 2015; 194:1587-93. [PMID: 26087383 DOI: 10.1016/j.juro.2015.06.075] [Citation(s) in RCA: 78] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/05/2015] [Indexed: 10/23/2022]
Abstract
PURPOSE In October 2011 the USPSTF (U.S. Preventive Services Task Force) issued a draft guideline discouraging prostate specific antigen based screening for prostate cancer (grade D recommendation). We evaluated the effect of the USPSTF guideline on the number and distribution of new prostate cancer diagnoses in the United States. MATERIALS AND METHODS We identified incident cancers diagnosed between January 2010 and December 2012 in NCDB (National Cancer Database). We performed an interrupted time series to evaluate the trend of new prostate cancers diagnosed each month before and after the draft guideline with colon cancer as a comparator. RESULTS Incident monthly prostate cancer diagnoses decreased by -1,363 cases (12.2%, p<0.01) in the month after the USPSTF draft guideline and continued to decrease by 164 cases per month relative to baseline (-1.8%, p<0.01). In contrast monthly colon cancer diagnoses remained stable. Diagnoses of low, intermediate and high risk prostate cancers decreased significantly but new diagnoses of nonlocalized disease did not change. Subgroups of age, comorbidity, race, income and insurance showed comparable decreases in incident prostate cancer following the draft guideline. CONCLUSIONS There was a 28% decrease in incident diagnoses of prostate cancer in the year after the USPSTF draft recommendation against prostate specific antigen screening. This study helps quantify the potential benefits (reduced harms of over diagnosis and overtreatment of low risk disease and disease found in elderly men) and potential harms (missed opportunities to diagnose important cancers in men who may benefit from treatment) of this guideline.
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Affiliation(s)
- Daniel A Barocas
- Center for Surgical Quality and Outcomes Research, Vanderbilt University Medical Center, Nashville, Tennessee.
| | - Katherine Mallin
- National Cancer Data Base, American College of Surgeons, Chicago, Illinois
| | - Amy J Graves
- Center for Surgical Quality and Outcomes Research, Vanderbilt University Medical Center, Nashville, Tennessee
| | - David F Penson
- Center for Surgical Quality and Outcomes Research, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Bryan Palis
- National Cancer Data Base, American College of Surgeons, Chicago, Illinois
| | - David P Winchester
- National Cancer Data Base, American College of Surgeons, Chicago, Illinois
| | - Sam S Chang
- Department of Urologic Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
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31
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Jackson JC, Morandi A, Girard TD, Merkle K, Graves AJ, Thompson JL, Shintani AK, Gunther ML, Cannistraci CJ, Rogers BP, Gore JC, Warrington HJ, Ely EW, Hopkins RO. Functional brain imaging in survivors of critical illness: A prospective feasibility study and exploration of the association between delirium and brain activation patterns. J Crit Care 2015; 30:653.e1-7. [PMID: 25769901 PMCID: PMC4489139 DOI: 10.1016/j.jcrc.2015.01.017] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [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: 09/08/2014] [Revised: 01/24/2015] [Accepted: 01/26/2015] [Indexed: 11/27/2022]
Abstract
PURPOSE We undertook this pilot prospective cohort investigation to examine the feasibility of functional magnetic resonance imaging (fMRI) assessments in survivors of critical illness and to analyze potential associations between delirium and brain activation patterns observed during a working memory task (N-back) at hospital discharge and 3-month follow-up. MATERIALS AND METHODS At hospital discharge and 3 months later, fMRI assessed subjects' functional activity during an N-back task. Multiple linear regression was used to examine associations between duration of delirium and brain activity, and elastic net regression was used to assess the relationship between brain activation patterns at 3 months and cognitive outcomes at 12 months. RESULTS Of 47 patients who underwent fMRI at discharge, 38 (80%) completed the protocol; of 37 who underwent fMRI at 3 months, 34 (91%) completed the protocol. At discharge, the mean (SD) percentage of correct responses on the most challenging version (the N2 version) of the N-back task was 70.4 (23.2; range of 20-100) compared with 76 (23.4; range of 33-100) at 3 months. No association was observed between delirium duration in the hospital and brain region activity in any brain region at discharge or 3 months after adjusting for relevant covariates (P values across all 11 brain regions of interest were >.25). CONCLUSIONS Our data support the feasibility of using fMRI in survivors of critical illness at 3-month follow-up but not at discharge. In this small study, delirium was not associated with distinct or abnormal brain activation patterns, although overall performance on a cognitive task of working memory was poorer than observed in other cohorts of individuals with medically related executive dysfunction, mild cognitive impairment, and mild traumatic brain injury.
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Affiliation(s)
- James C Jackson
- Division of Allergy, Pulmonary, and Critical Care Medicine, Department of Medicine, Vanderbilt University School of Medicine, Nashville, TN; Center for Health Services Research, Department of Medicine, Vanderbilt University School of Medicine, Nashville, TN; Department of Psychiatry, Vanderbilt University School of Medicine, Nashville, TN; Research Service, Department of Veterans Affairs Medical Center, Tennessee Valley Healthcare System, Nashville, TN.
| | - Alessandro Morandi
- Department of Rehabilitation and Aged Care Unit, Hospital Ancelle, Cremona, Italy
| | - Timothy D Girard
- Division of Allergy, Pulmonary, and Critical Care Medicine, Department of Medicine, Vanderbilt University School of Medicine, Nashville, TN; Center for Health Services Research, Department of Medicine, Vanderbilt University School of Medicine, Nashville, TN; Geriatric Research, Education and Clinical Center (GRECC) Service, Department of Veterans Affairs Medical Center, Tennessee Valley Healthcare System, Nashville, TN
| | - Kristen Merkle
- Vanderbilt University Institute of Imaging Sciences, Nashville, TN
| | - Amy J Graves
- Department of Urologic Surgery, Vanderbilt University School of Medicine, Nashville, TN
| | - Jennifer L Thompson
- Department of Clinical Epidemiology and Biostatistics, Osaka University, Osaka, Japan
| | - Ayumi K Shintani
- Department of Veterans Affairs Medical Center, Tennessee Valley Healthcare System, Nashville, TN
| | - Max L Gunther
- Vanderbilt University Institute of Imaging Sciences, Nashville, TN; Department of Psychology, Vanderbilt University, Nashville, TN; Department of Psychology, Southern Methodist University, Dallas, TX
| | | | - Baxter P Rogers
- Department of Psychiatry, Vanderbilt University School of Medicine, Nashville, TN; Department of Biomedical Engineering, Vanderbilt University School of Engineering, Nashville, TN; Department of Radiology and Radiological Sciences, Vanderbilt University School of Medicine, Nashville, TN
| | - John C Gore
- Department of Biomedical Engineering, Vanderbilt University School of Engineering, Nashville, TN; Department of Radiology and Radiological Sciences, Vanderbilt University School of Medicine, Nashville, TN
| | - Hillary J Warrington
- Division of Allergy, Pulmonary, and Critical Care Medicine, Department of Medicine, Vanderbilt University School of Medicine, Nashville, TN; Center for Health Services Research, Department of Medicine, Vanderbilt University School of Medicine, Nashville, TN
| | - E Wesley Ely
- Division of Allergy, Pulmonary, and Critical Care Medicine, Department of Medicine, Vanderbilt University School of Medicine, Nashville, TN; Center for Health Services Research, Department of Medicine, Vanderbilt University School of Medicine, Nashville, TN; Geriatric Research, Education and Clinical Center (GRECC) Service, Department of Veterans Affairs Medical Center, Tennessee Valley Healthcare System, Nashville, TN
| | - Ramona O Hopkins
- Department of Psychology, Brigham Young University, Provo, UT; Department of Medicine, Pulmonary and Critical Care Division, Intermountain Medical Center, Murray UT; Neuroscience Center, Brigham Young University, Provo, UT
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Morgans AK, Graves AJ, Penson DF. Bisphosphonate utilization among men with metastatic castration-resistant prostate cancer (CRPC). J Clin Oncol 2015. [DOI: 10.1200/jco.2015.33.15_suppl.e16088] [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: 11/20/2022] Open
Affiliation(s)
| | - Amy J Graves
- Vanderbilt University Medical Center, Nashville, TN
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Inoue S, Vasilevskis EE, Pandharipande PP, Girard TD, Graves AJ, Thompson J, Shintani A, Ely EW. The impact of lymphopenia on delirium in ICU patients. PLoS One 2015; 10:e0126216. [PMID: 25992641 PMCID: PMC4439144 DOI: 10.1371/journal.pone.0126216] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2015] [Accepted: 03/31/2015] [Indexed: 12/01/2022] Open
Abstract
Background Immunosuppressed states may predispose patients to development of acute brain injury during times of critical illness. Lymphopenia is a non-specific yet commonly used bedside marker of immunosuppressed states. Methods We examined whether lymphopenia would predict development of acute brain dysfunction (delirium and/or coma) in 518 patients enrolled in the Bringing to Light the Risk Factors and Incidence of Neuropsychological Dysfunction in ICU Survivors (BRAIN-ICU) study in medical and surgical ICUs of a tertiary care, university-based medical center. Utilizing proportional odds logistic regression and Cox proportional hazards survival analysis, we assessed the relationship between pre-enrollment lymphocytes and subsequent cognitive outcomes including delirium- and coma-free days (DCFDs) and 30-day mortality. Results There were no statistically significant associations between lymphocytes and DCFDs (p = 0.17); additionally, the relationship between lymphocytes and mortality was not statistically significant (p = 0.71). Among 259 patients without history of cancer or diabetes, there was no statistically significant association between lymphocytes and DCFDs (p = 0.07). Conclusion lymphopenia, a commonly used bedside marker of immunosuppression, does not appear to be a marker of risk for acute brain injury (delirium/coma) or 30-day mortality in general medical/surgical ICU patients.
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Affiliation(s)
- Shigeaki Inoue
- Department of Emergency and Critical Care Medicine, Tokai University School of Medicine, Isehara, Kanagawa, Japan
- * E-mail:
| | - Eduard E. Vasilevskis
- Division of General Internal Medicine and Public Health, Department of Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee, United States of America
- Veterans Affairs Tennessee Valley Geriatric Research, Education and Clinical Center (GRECC), Vanderbilt University School of Medicine, Nashville, Tennessee, United States of America
| | - Pratik P. Pandharipande
- Department of Anesthesiology, Vanderbilt University School of Medicine, Nashville, Tennessee, United States of America
| | - Timothy D. Girard
- Division of Allergy/Pulmonary/Critical Care Medicine, Department of Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee, United States of America
- Veterans Affairs Tennessee Valley Geriatric Research, Education and Clinical Center (GRECC), Vanderbilt University School of Medicine, Nashville, Tennessee, United States of America
| | - Amy J. Graves
- Department of Biostatistics, Vanderbilt University School of Medicine Nashville, Tennessee, United States of America
| | - Jennifer Thompson
- Department of Biostatistics, Vanderbilt University School of Medicine Nashville, Tennessee, United States of America
| | - Ayumi Shintani
- Department of Biostatistics, Vanderbilt University School of Medicine Nashville, Tennessee, United States of America
| | - E. Wesley Ely
- Division of Allergy/Pulmonary/Critical Care Medicine, Department of Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee, United States of America
- Veterans Affairs Tennessee Valley Geriatric Research, Education and Clinical Center (GRECC), Vanderbilt University School of Medicine, Nashville, Tennessee, United States of America
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Affiliation(s)
- J Frank Wharam
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, Massachusetts
| | - Amy J Graves
- Department of Urologic Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Katy B Kozhimannil
- Division of Health Policy and Management, University of Minnesota School of Public Health, Minneapolis
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Han JH, Vasilevskis EE, Shintani A, Graves AJ, Schnelle JF, Dittus RS, Powers JS, Wilson A, Storrow AB, Ely EW. Impaired arousal at initial presentation predicts 6-month mortality: an analysis of 1084 acutely ill older patients. J Hosp Med 2014; 9:772-8. [PMID: 25352356 PMCID: PMC4326096 DOI: 10.1002/jhm.2276] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2014] [Revised: 09/24/2014] [Accepted: 10/03/2014] [Indexed: 01/09/2023]
Abstract
OBJECTIVES Impaired arousal signifies underlying brain dysfunction, but its clinical significance outside the intensive care unit remains unclear. We sought to determine if impaired arousal at initial presentation was associated with higher 6-month mortality and if this relationship existed in the absence of delirium. DESIGN Prospective cohort study. SETTING An emergency department located within an academic, tertiary care hospital. PARTICIPANTS A total of 1084 noncomatose patients who were aged 65 years or older. MEASUREMENTS The Richmond Agitation-Sedation Scale (RASS) is a 10-second arousal scale; a score of 0 indicates normal arousal. Cox proportional hazard regression was performed adjusting for patient characteristics, admission status, and psychoactive medication administration. To determine if impaired arousal in the absence of delirium was associated with 6-month mortality, Cox proportional hazard regression was performed in a subset of 406 patients who received a psychiatric assessment; the inverse weighted propensity score method was used to minimize residual confounding. Hazard ratios (HR) with their 95% confidence intervals (95% CI) were reported. RESULTS Patients with impaired arousal were 73% more likely to die within 6 months (HR: 1.73, 95% CI: 1.21-2.49). Even in the absence of delirium, patients with an abnormal RASS were more likely to die within 6 months (HR: 2.20, 95% CI: 1.10-4.41). CONCLUSION Impaired arousal at initial presentation is an independent predictor of death within 6 months in a diverse group of acutely ill older patients, even in the absence of delirium. Routine RASS assessment of arousal during clinical care may be warranted as it correlates with prognosis.
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Affiliation(s)
- Jin H. Han
- Center for Quality Aging, Vanderbilt University School of Medicine, Nashville, TN
- Department of Emergency Medicine, Vanderbilt University School of Medicine, Nashville, TN
| | - Eduard E. Vasilevskis
- Center for Quality Aging, Vanderbilt University School of Medicine, Nashville, TN
- Department of Medicine, Division of General Internal Medicine and Public Health, Vanderbilt University School of Medicine, Nashville, TN
- Center for Health Services Research; Vanderbilt University School of Medicine, Nashville, TN
- Geriatric Research, Education, and Clinical Center, Veterans Affairs Tennessee Valley Healthcare System, Nashville, TN
| | - Ayumi Shintani
- Department of Biostatistics, Vanderbilt University School of Medicine, Nashville, TN
| | - Amy J. Graves
- Department of Urologic Surgery, Vanderbilt University School of Medicine, Nashville, TN
| | - John F. Schnelle
- Center for Quality Aging, Vanderbilt University School of Medicine, Nashville, TN
- Department of Medicine, Division of General Internal Medicine and Public Health, Vanderbilt University School of Medicine, Nashville, TN
- Geriatric Research, Education, and Clinical Center, Veterans Affairs Tennessee Valley Healthcare System, Nashville, TN
| | - Robert S. Dittus
- Department of Medicine, Division of General Internal Medicine and Public Health, Vanderbilt University School of Medicine, Nashville, TN
- Center for Health Services Research; Vanderbilt University School of Medicine, Nashville, TN
- Geriatric Research, Education, and Clinical Center, Veterans Affairs Tennessee Valley Healthcare System, Nashville, TN
| | - James S. Powers
- Center for Quality Aging, Vanderbilt University School of Medicine, Nashville, TN
- Department of Medicine, Division of General Internal Medicine and Public Health, Vanderbilt University School of Medicine, Nashville, TN
- Geriatric Research, Education, and Clinical Center, Veterans Affairs Tennessee Valley Healthcare System, Nashville, TN
| | - Amanda Wilson
- Department of Psychiatry, Vanderbilt University School of Medicine, Nashville, TN
| | - Alan B. Storrow
- Department of Emergency Medicine, Vanderbilt University School of Medicine, Nashville, TN
| | - E. Wesley Ely
- Center for Health Services Research; Vanderbilt University School of Medicine, Nashville, TN
- Geriatric Research, Education, and Clinical Center, Veterans Affairs Tennessee Valley Healthcare System, Nashville, TN
- Department of Medicine, Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University School of Medicine, Nashville, TN
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Hung AM, Booker C, Ellis CD, Siew ED, Graves AJ, Shintani A, Abumrad NN, Himmelfarb J, Ikizler TA. Omega-3 fatty acids inhibit the up-regulation of endothelial chemokines in maintenance hemodialysis patients. Nephrol Dial Transplant 2014; 30:266-74. [PMID: 25204316 DOI: 10.1093/ndt/gfu283] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.6] [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] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Chronic systemic inflammation is common in patients with chronic kidney disease on dialysis (CKD5D) and has been considered a key mediator of the increased cardiovascular risk in this patient population. In this study, we tested the hypothesis that supplementation of omega-3 polyunsaturated fatty acids (ω-3 PUFAs) will attenuate the systemic inflammatory process in CKD5D patients. METHODS The design was a randomized, double-blinded, placebo controlled pilot trial (NCT00655525). Thirty-eight patients were randomly assigned in a 1 : 1 fashion to receive 2.9 g of eicosapentaenoic acid (C20:5, n-3) plus docosahexaenoic acid (C22:6, n-3) versus placebo for 12 weeks. The primary outcome was change in pro-inflammatory chemokines measured by lipopolysaccharide (LPS)-stimulated peripheral blood mononuclear cells (PBMCs). Secondary outcomes were changes in systemic inflammatory markers. Analysis of covariance was used to compare percent change from baseline to 12 weeks. RESULTS Thirty-one patients completed 12 weeks and three patients completed 6 weeks of the study. Median age was 52 (interquartile range 45, 60) years, 74% were African-American and 79% were male. Supplementation of ω-3 PUFAs effectively decreased the LPS-induced PBMC expression of RANTES (Regulated upon Activation, Normal T cell Expressed and Secreted) and MCP-1 (Monocyte Chemotactic Protein-1; unadjusted P = 0.04 and 0.06; adjusted for demographics P = 0.02 and 0.05, respectively). There was no significant effect of the intervention on serum inflammatory markers (C-reactive protein, interleukin-6 and procalcitonin). CONCLUSIONS The results of this pilot study suggest that supplementation of ω-3 PUFAs is beneficial in decreasing the levels of endothelial chemokines, RANTES and MCP-1. Studies of larger sample size and longer duration are required to further evaluate effects of ω-3 PUFAs on systemic markers of inflammation, other metabolic parameters and clinical outcomes, particularly cardiovascular outcomes in CKD5D patients.
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Affiliation(s)
- Adriana M Hung
- CSR&D, Veterans Administration Tennessee Valley Healthcare System, Nashville, TN, USA Division of Nephrology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Cindy Booker
- Division of Nephrology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Charles D Ellis
- Division of Nephrology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Edward D Siew
- CSR&D, Veterans Administration Tennessee Valley Healthcare System, Nashville, TN, USA Division of Nephrology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Amy J Graves
- Division of Biostatistics, Vanderbilt University, Nashville, TN, USA
| | - Ayumi Shintani
- Division of Biostatistics, Vanderbilt University, Nashville, TN, USA
| | - Naji N Abumrad
- Department of Surgery, Vanderbilt University, Nashville, TN, USA
| | | | - Talat Alp Ikizler
- CSR&D, Veterans Administration Tennessee Valley Healthcare System, Nashville, TN, USA Division of Nephrology, Vanderbilt University Medical Center, Nashville, TN, USA
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Ritch CR, Graves AJ, Keegan KA, Ni S, Bassett JC, Chang SS, Resnick MJ, Penson DF, Barocas DA. Increasing use of observation among men at low risk for prostate cancer mortality. J Urol 2014; 193:801-6. [PMID: 25196658 DOI: 10.1016/j.juro.2014.08.102] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/22/2014] [Indexed: 11/16/2022]
Abstract
PURPOSE There are growing concerns regarding the overtreatment of localized prostate cancer. It is also relatively unknown whether there has been increased uptake of observational strategies for disease management. We assessed the temporal trend in observation of clinically localized prostate cancer, particularly in men with low risk disease, who were young and healthy enough to undergo treatment. MATERIALS AND METHODS We performed a retrospective cohort study using the SEER-Medicare database in 66,499 men with localized prostate cancer between 2004 and 2009. The main study outcome was observation within 1 year after diagnosis. We performed multivariable analysis to develop a predictive model of observation adjusting for diagnosis year, age, risk and comorbidity. RESULTS Observation was performed in 12,007 men (18%) with a slight increase with time from 17% to 20%. However, there was marked increase in observation from 18% in 2004 to 29% in 2009 in men with low risk disease. Men 66 to 69 years old with low risk disease and no comorbidities had twice the odds of undergoing observation in 2009 vs 2004 (OR 2.12, 95% CI 1.73-2.59). Age, risk group, comorbidity and race were independent predictors of observation (each p <0.001), in addition to diagnosis year. CONCLUSIONS We identified increasing use of observation for low risk prostate cancer between 2004 and 2009 even in men young and healthy enough for treatment. This suggests growing acceptance of surveillance in this group of patients.
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Affiliation(s)
- Chad R Ritch
- Department of Urology, University of Miami, Miami, Florida.
| | - Amy J Graves
- Vanderbilt University Medical Center, Nashville, Tennessee
| | - Kirk A Keegan
- Division of Urology, San Antonio Military Medical Center, San Antonio, Texas
| | - Shenghua Ni
- Center for Surgical Quality and Outcomes Research, Nashville, Tennessee
| | | | - Sam S Chang
- Department of Urologic Surgery, Nashville, Tennessee
| | | | - David F Penson
- Vanderbilt University Medical Center, Nashville, Tennessee
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Limkunakul C, Sundell MB, Pouliot B, Graves AJ, Shintani A, Ikizler TA. Glycemic load is associated with oxidative stress among prevalent maintenance hemodialysis patients. Nephrol Dial Transplant 2014; 29:1047-53. [PMID: 24353320 PMCID: PMC4055829 DOI: 10.1093/ndt/gft489] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2013] [Accepted: 11/02/2013] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND High glycemic index (GI) and glycemic load (GL) are associated with increased levels of oxidative stress and systemic inflammation in the general population. Maintenance hemodialysis (MHD) patients are known to have excessive oxidative stress burden and inflammation. In this study, we examined the relationship between dietary GI or GL and markers of oxidative stress or inflammation among prevalent MHD patients. METHODS A registered dietitian obtained GI, GL and other dietary data from 58 MHD patients. Two separate 24-h diet recalls (a hemodialysis day and a non-hemodialysis day) were analyzed using the Nutrition Data System for Research (NDS-R) software. Plasma or serum concentrations of F2-isoprostanes, high sensitivity C-reactive protein (hsCRP), leptin and adiponectin (ADPN) were measured in fasting state. Fat mass was measured by dual-energy X-ray absorptiometry (DEXA). Cross-sectional associations between GI, GL and markers of interest were examined by multiple regression analysis with adjustment for potential covariates. RESULTS Mean (±SD) age, body mass index (BMI) and total trunk fat were 47 ± 12 years, 29.5 ± 6.8 kg/m(2) and 16.4 ± 8.8 kg, respectively. Dietary GI was associated with trunk fat (r = -0.182, P = 0.05) but not with F2-isoprostanes and hsCRP. In contrast, GL was significantly associated with F2-isoprostanes (P = 0.002), in unadjusted analysis, which remained in adjusted analyses, adjusting for age and sex (P = 0.005), and after adjusting for BMI, trunk fat and waist/hip ratio (P = 0.004). Addition of leptin or ADPN did not alter the significance of the association. GL also correlated with hsCRP (P = 0.03), but this association was modified by BMI and trunk fat. CONCLUSIONS Dietary GL is significantly associated with markers of oxidative stress and inflammation among prevalent MHD patients, independent of the body composition and adipocytokines. These data indicate the importance of the contents of dietary nutrient intake composition and its potential role in determining the metabolic disturbances in MHD patients.
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Affiliation(s)
- Chutatip Limkunakul
- Department of Medicine, Division of Nephrology, Vanderbilt University School of Medicine, Nashville, TN, USA
- Department of Medicine, Panyananthaphikku Chonprathan Medical Center, Srinakharinwirot University, Pakkret, Thailand
| | - Mary B. Sundell
- Department of Medicine, Division of Nephrology, Vanderbilt University School of Medicine, Nashville, TN, USA
| | - Brianna Pouliot
- Department of Medicine, Division of Nephrology, Vanderbilt University School of Medicine, Nashville, TN, USA
| | - Amy J. Graves
- Department of Biostatistics, Vanderbilt University School of Medicine, Nashville, TN, USA
| | - Ayumi Shintani
- Department of Biostatistics, Vanderbilt University School of Medicine, Nashville, TN, USA
| | - Talat A. Ikizler
- Department of Medicine, Division of Nephrology, Vanderbilt University School of Medicine, Nashville, TN, USA
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Brummel NE, Girard TD, Ely EW, Pandharipande PP, Morandi A, Hughes CG, Graves AJ, Shintani A, Murphy E, Work B, Pun BT, Boehm L, Gill TM, Dittus RS, Jackson JC. Feasibility and safety of early combined cognitive and physical therapy for critically ill medical and surgical patients: the Activity and Cognitive Therapy in ICU (ACT-ICU) trial. Intensive Care Med 2014; 40:370-9. [PMID: 24257969 PMCID: PMC3943568 DOI: 10.1007/s00134-013-3136-0] [Citation(s) in RCA: 154] [Impact Index Per Article: 15.4] [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: 07/29/2013] [Accepted: 10/07/2013] [Indexed: 12/21/2022]
Abstract
PURPOSE Cognitive impairment after critical illness is common and debilitating. We developed a cognitive therapy program for critically ill patients and assessed the feasibility and safety of administering combined cognitive and physical therapy early during a critical illness. METHODS We randomized 87 medical and surgical ICU patients with respiratory failure and/or shock in a 1:1:2 manner to three groups: usual care, early once-daily physical therapy, or early once-daily physical therapy plus a novel, progressive, twice-daily cognitive therapy protocol. Cognitive therapy included orientation, memory, attention, and problem-solving exercises, and other activities. We assessed feasibility outcomes of the early cognitive plus physical therapy intervention. At 3 months, we also assessed cognitive, functional, and health-related quality of life outcomes. Data are presented as median (interquartile range) or frequency (%). RESULTS Early cognitive therapy was a delivered to 41/43 (95%) of cognitive plus physical therapy patients on 100% (92-100%) of study days beginning 1.0 (1.0-1.0) day following enrollment. Physical therapy was received by 17/22 (77%) of usual care patients, by 21/22 (95%) of physical therapy only patients, and 42/43 (98%) of cognitive plus physical therapy patients on 17% (10-26%), 67% (46-87%), and 75% (59-88%) of study days, respectively. Cognitive, functional, and health-related quality of life outcomes did not differ between groups at 3-month follow-up. CONCLUSIONS This pilot study demonstrates that early rehabilitation can be extended beyond physical therapy to include cognitive therapy. Future work to determine optimal patient selection, intensity of treatment, and benefits of cognitive therapy in the critically ill is needed.
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Affiliation(s)
- N E Brummel
- Division of Allergy, Pulmonary, and Critical Care Medicine, Department of Medicine, Vanderbilt University School of Medicine, 2525 West End Avenue, Suite 350, Nashville, TN, 37203-1425, USA,
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Abstract
OBJECTIVES Recent data showing possible increased risk for suicidal behavior among children and adolescents treated with selective serotonin reuptake inhibitors (SSRIs) and serotonin-norepinephrine reuptake inhibitors (SNRIs) antidepressants have created significant concern among patients, families, and providers, including concerns about the risk of individual antidepressants. This study was designed to compare the risk for medically treated suicide attempts among new users of sertraline, paroxetine, citalopram, escitalopram, and venlafaxine to risk for new users of fluoxetine. METHODS A retrospective cohort study included 36,842 children aged 6 to 18 years enrolled in Tennessee Medicaid between 1995 and 2006 who were new users of 1 of the antidepressant medications of interest (defined as filling no prescriptions for antidepressants in the preceding 365 days). Medically treated suicide attempts were identified from Medicaid files and vital records and confirmed with medical record review. RESULTS Four hundred nineteen cohort members had a medically treated suicide attempt with explicit or inferred attempt to die confirmed through medical record review, including 4 who completed suicide. The rate of confirmed suicide attempts for the study drugs ranged from 24.0 per 1000 person-years to 29.1 per 1000 person-years. The adjusted rate of suicide attempts did not differ significantly among current users of SSRI and SNRI antidepressants compared with current users of fluoxetine. Users of multiple antidepressants concomitantly had increased risk for suicide attempt. CONCLUSIONS In this population-based study of children recently initiating an antidepressant, there was no evidence that risk of suicide attempts differed for commonly prescribed SSRI and SNRI antidepressants.
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Affiliation(s)
| | | | | | - D. Catherine Fuchs
- Psychiatry, Vanderbilt University School of Medicine, Nashville, Tennessee; and
| | - Richard C. Shelton
- Department of Psychiatry, University of Alabama Birmingham, Birmingham, Alabama
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Han JH, Wilson A, Graves AJ, Shintani A, Schnelle JF, Dittus RS, Powers JS, Vernon J, Storrow AB, Ely EW. Validation of the Confusion Assessment Method for the Intensive Care Unit in older emergency department patients. Acad Emerg Med 2014; 21:180-7. [PMID: 24673674 DOI: 10.1111/acem.12309] [Citation(s) in RCA: 68] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2013] [Revised: 08/09/2013] [Accepted: 08/22/2013] [Indexed: 11/27/2022]
Abstract
OBJECTIVES In the emergency department (ED), health care providers miss delirium approximately 75% of the time, because they do not routinely screen for this syndrome. The Confusion Assessment Method for the Intensive Care Unit (CAM-ICU) is a brief (<1 minute) delirium assessment that may be feasible for use in the ED. The study objective was to determine its validity and reliability in older ED patients. METHODS In this prospective observational cohort study, patients aged 65 years or older were enrolled at an academic, tertiary care ED from July 2009 to February 2012. An emergency physician (EP) and research assistants (RAs) performed the CAM-ICU. The reference standard for delirium was a comprehensive (~30 minutes) psychiatrist assessment using the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision criteria. All assessments were blinded to each other and were conducted within 3 hours. Sensitivities, specificities, and likelihood ratios were calculated for both the EP and the RAs using the psychiatrist's assessment as the reference standard. Kappa values between the EP and RAs were also calculated to measure reliability. RESULTS Of 406 patients enrolled, 50 (12.3%) had delirium. The median age was 73.5 years old (interquartile range [IQR] = 69 to 80 years), 202 (49.8%) were female, and 57 (14.0%) were nonwhite. The CAM-ICU's sensitivities were 72.0% (95% confidence interval [CI] = 58.3% to 82.5%) and 68.0% (95% CI = 54.2% to 79.2%) in the EP and RAs, respectively. The CAM-ICU's specificity was 98.6% (95% CI = 96.8% to 99.4%) for both raters. The negative likelihood ratios (LR-) were 0.28 (95% CI = 0.18 to 0.44) and 0.32 (95% CI = 0.22 to 0.49) in the EP and RAs, respectively. The positive likelihood ratios (LR+) were 51.3 (95% CI = 21.1 to 124.5) and 48.4 (95% CI = 19.9 to 118.0), respectively. The kappa between the EP and RAs was 0.92 (95% CI = 0.85 to 0.98), indicating excellent interobserver reliability. CONCLUSIONS In older ED patients, the CAM-ICU is highly specific, and a positive test is nearly diagnostic for delirium when used by both the EP and RAs. However, the CAM-ICU's sensitivity was modest, and a negative test decreased the likelihood of delirium by a small amount. The consequences of a false-negative CAM-ICU are unknown and deserve further study.
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Affiliation(s)
- Jin H. Han
- Center for Quality Aging; Vanderbilt University School of Medicine; Nashville TN
- Department of Emergency Medicine; Vanderbilt University School of Medicine; Nashville TN
| | - Amanda Wilson
- Department of Psychiatry; Vanderbilt University School of Medicine; Nashville TN
| | - Amy J. Graves
- Department of Biostatistics; Vanderbilt University School of Medicine; Nashville TN
| | - Ayumi Shintani
- Department of Biostatistics; Vanderbilt University School of Medicine; Nashville TN
| | - John F. Schnelle
- Center for Quality Aging; Vanderbilt University School of Medicine; Nashville TN
- Division of General Internal Medicine and Public Health; Vanderbilt University School of Medicine; Nashville TN
- Geriatric Research, Education, and Clinical Center; Department of Veterans Affairs Medical Center; Tennessee Valley Health Care Center; Nashville TN
| | - Robert S. Dittus
- Division of General Internal Medicine and Public Health; Vanderbilt University School of Medicine; Nashville TN
- Center for Health Services Research; Vanderbilt University School of Medicine; Nashville TN
- Geriatric Research, Education, and Clinical Center; Department of Veterans Affairs Medical Center; Tennessee Valley Health Care Center; Nashville TN
| | - James S. Powers
- Center for Quality Aging; Vanderbilt University School of Medicine; Nashville TN
- Division of General Internal Medicine and Public Health; Vanderbilt University School of Medicine; Nashville TN
- Geriatric Research, Education, and Clinical Center; Department of Veterans Affairs Medical Center; Tennessee Valley Health Care Center; Nashville TN
| | - John Vernon
- Department of Psychiatry; Virginia Commonwealth University Medical Center; Richmond VA
| | - Alan B. Storrow
- Department of Emergency Medicine; Vanderbilt University School of Medicine; Nashville TN
| | - E. Wesley Ely
- Center for Quality Aging; Vanderbilt University School of Medicine; Nashville TN
- Center for Health Services Research; Vanderbilt University School of Medicine; Nashville TN
- Division of Allergy, Pulmonary; and Critical Care Medicine; Vanderbilt University School of Medicine; Nashville TN
- Geriatric Research, Education, and Clinical Center; Department of Veterans Affairs Medical Center; Tennessee Valley Health Care Center; Nashville TN
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Han JH, Wilson A, Vasilevskis EE, Shintani A, Schnelle JF, Dittus RS, Graves AJ, Storrow AB, Shuster J, Ely EW. Diagnosing delirium in older emergency department patients: validity and reliability of the delirium triage screen and the brief confusion assessment method. Ann Emerg Med 2013; 62:457-465. [PMID: 23916018 DOI: 10.1016/j.annemergmed.2013.05.003] [Citation(s) in RCA: 202] [Impact Index Per Article: 18.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2013] [Revised: 04/29/2013] [Accepted: 05/06/2013] [Indexed: 01/20/2023]
Abstract
STUDY OBJECTIVE Delirium is a common form of acute brain dysfunction with prognostic significance. Health care professionals caring for older emergency department (ED) patients miss delirium in approximately 75% of cases. This error results from a lack of available measures that can be performed rapidly enough to be incorporated into clinical practice. Therefore, we developed and evaluated a novel 2-step approach to delirium surveillance for the ED. METHODS This prospective observational study was conducted at an academic ED in patients aged 65 years or older. A research assistant and physician performed the Delirium Triage Screen (DTS), designed to be a highly sensitive rule-out test, and the Brief Confusion Assessment Method (bCAM), designed to be a highly specific rule-in test for delirium. The reference standard for delirium was a comprehensive psychiatrist assessment using Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision criteria. All assessments were independently conducted within 3 hours of one another. Sensitivities, specificities, and likelihood ratios with their 95% confidence intervals (95% CIs) were calculated. RESULTS Of 406 enrolled patients, 50 (12.3%) had delirium diagnosed by the psychiatrist reference standard. The DTS was 98.0% sensitive (95% CI 89.5% to 99.5%), with an expected specificity of approximately 55% for both raters. The DTS's negative likelihood ratio was 0.04 (95% CI 0.01 to 0.25) for both raters. As the complement, the bCAM had a specificity of 95.8% (95% CI 93.2% to 97.4%) and 96.9% (95% CI 94.6% to 98.3%) and a sensitivity of 84.0% (95% CI 71.5% to 91.7%) and 78.0% (95% CI 64.8% to 87.2%) when performed by the physician and research assistant, respectively. The positive likelihood ratios for the bCAM were 19.9 (95% CI 12.0 to 33.2) and 25.2 (95% CI 13.9 to 46.0), respectively. If the research assistant DTS was followed by the physician bCAM, the sensitivity of this combination was 84.0% (95% CI 71.5% to 91.7%) and specificity was 95.8% (95% CI 93.2% to 97.4%). If the research assistant performed both the DTS and bCAM, this combination was 78.0% sensitive (95% CI 64.8% to 87.2%) and 97.2% specific (95% CI 94.9% to 98.5%). If the physician performed both the DTS and bCAM, this combination was 82.0% sensitive (95% CI 69.2% to 90.2%) and 95.8% specific (95% CI 93.2% to 97.4%). CONCLUSION In older ED patients, this 2-step approach (highly sensitive DTS followed by highly specific bCAM) may enable health care professionals, regardless of clinical background, to efficiently screen for delirium. Larger, multicenter trials are needed to confirm these findings and to determine the effect of these assessments on delirium recognition in the ED.
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Affiliation(s)
- Jin H Han
- Center for Quality Aging, Vanderbilt University School of Medicine, Nashville, TN; Department of Emergency Medicine, Vanderbilt University School of Medicine, Nashville, TN.
| | - Amanda Wilson
- Department of Psychiatry, Vanderbilt University School of Medicine, Nashville, TN
| | - Eduard E Vasilevskis
- Center for Quality Aging, Vanderbilt University School of Medicine, Nashville, TN; Department of Medicine, Division of General Internal Medicine and Public Health, Vanderbilt University School of Medicine, Nashville, TN; Center for Health Services Research, Vanderbilt University School of Medicine, Nashville, TN; Geriatric Research, Education, and Clinical Center (GRECC), Department of Veterans Affairs Medical Center, Tennessee Valley Health Care Center, Nashville, TN
| | - Ayumi Shintani
- Department of Biostatistics, Vanderbilt University School of Medicine, Nashville, TN
| | - John F Schnelle
- Center for Quality Aging, Vanderbilt University School of Medicine, Nashville, TN; Department of Medicine, Division of General Internal Medicine and Public Health, Vanderbilt University School of Medicine, Nashville, TN; Center for Health Services Research, Vanderbilt University School of Medicine, Nashville, TN; Geriatric Research, Education, and Clinical Center (GRECC), Department of Veterans Affairs Medical Center, Tennessee Valley Health Care Center, Nashville, TN
| | - Robert S Dittus
- Department of Medicine, Division of General Internal Medicine and Public Health, Vanderbilt University School of Medicine, Nashville, TN; Center for Health Services Research, Vanderbilt University School of Medicine, Nashville, TN; Geriatric Research, Education, and Clinical Center (GRECC), Department of Veterans Affairs Medical Center, Tennessee Valley Health Care Center, Nashville, TN
| | - Amy J Graves
- Department of Biostatistics, Vanderbilt University School of Medicine, Nashville, TN
| | - Alan B Storrow
- Department of Emergency Medicine, Vanderbilt University School of Medicine, Nashville, TN
| | - John Shuster
- Department of Psychiatry, Vanderbilt University School of Medicine, Nashville, TN
| | - E Wesley Ely
- Center for Quality Aging, Vanderbilt University School of Medicine, Nashville, TN; Center for Health Services Research, Vanderbilt University School of Medicine, Nashville, TN; Department of Internal Medicine, Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University School of Medicine, Nashville, TN; Geriatric Research, Education, and Clinical Center (GRECC), Department of Veterans Affairs Medical Center, Tennessee Valley Health Care Center, Nashville, TN
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Wagner AK, Graves AJ, Fan Z, Walker S, Zhang F, Ross-Degnan D. Need for and access to health care and medicines: are there gender inequities? PLoS One 2013; 8:e57228. [PMID: 23505420 PMCID: PMC3591435 DOI: 10.1371/journal.pone.0057228] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2012] [Accepted: 01/18/2013] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVE Differences between women and men in political and economic empowerment, education, and health risks are well-documented. Similar gender inequities in access to care and medicines have been hypothesized but evidence is lacking. METHODS We analyzed 2002 World Health Survey data for 257,922 adult respondents and 80,932 children less than 5 years old from 53 mostly low and middle-income countries. We constructed indicators of need for, access to, and perceptions of care, and we described the number of countries with equal and statistically different proportions of women and men for each indicator. Using multivariate logistic regression models, we estimated effects of gender on our study outcomes, overall and by household poverty. FINDINGS Women reported significantly more need for care for three of six chronic conditions surveyed, and they were more likely to have at least one of the conditions (OR 1.41 [95% CI 1.38, 1.44]). Among those with reported need for care, there were no consistent differences in access to care between women and men overall (e.g., treatment for all reported chronic conditions, OR 1.00 [0.96, 1.04]) or by household poverty. Of concern, access to care for chronic conditions was distressingly low among both men and women in many countries, as was access to preventive services among boys and girls less than 5 years old. CONCLUSIONS These cross-country results do not suggest a systematic disadvantage of women in access to curative care and medicines for treating selected chronic conditions or acute symptoms, or to preventive services among boys and girls.
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Affiliation(s)
- Anita K Wagner
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, Massachusetts, United States of America.
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Wagner AK, Valera M, Graves AJ, Laviña S, Ross-Degnan D. Costs of hospital care for hypertension in an insured population without an outpatient medicines benefit: an observational study in the Philippines. BMC Health Serv Res 2008; 8:161. [PMID: 18664285 PMCID: PMC2518143 DOI: 10.1186/1472-6963-8-161] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2008] [Accepted: 07/29/2008] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Hypertension is the number one attributable risk factor for death throughout the world and a major contributor to morbidity, mortality, and increasing health care expenditures in the Philippines. Lack of access to outpatient antihypertensive medicines leads to avoidable disease progression and costly inpatient admissions. We estimated the cost to the Philippine Health Insurance Corporation (PhilHealth), which generally does not cover outpatient medicines, for inpatient care for hypertension and its sequelae. METHODS Using PhilHealth inpatient claims for discharges between July 1, 2002 and December 31, 2005, we describe costs to PhilHealth for hospitalizations classified by primary discharge diagnoses into hospitalizations for hypertension; hypertensive heart and/or renal disease; other definite; and other possible consequences of untreated hypertension and assess disease trajectory for patients with more than one admission. RESULTS PhilHealth reimbursed US $56 million for 444,628 hospitalizations for hypertension-related diagnoses incurred by 360,016 patients during 3.5 years; 42% of admissions were for essential or secondary hypertension; 19% for hypertensive heart or renal disease; and 39% for other consequences of untreated hypertension. Among 60,659 patients admitted during the first 18 months of the study with a diagnosis of essential or secondary hypertension, 9% were hospitalized again for treatment of sequelae; older individuals (vs. = or < 40 years old), men, dependents (vs. members), and those who were employed (vs. in the private membership category) were more likely to be hospitalized again; as were those whose first admission during the study period was for consequences of hypertension (vs. essential or secondary hypertension). CONCLUSION Inpatient care for hypertension and its sequelae is expensive. Since many hospitalizations may be avoided with antihypertensive pharmacologic therapy, an outpatient medicines benefit may be one cost-effective policy option for PhilHealth.
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Affiliation(s)
- Anita K Wagner
- Department of Ambulatory Care and Prevention, Harvard Medical School and Harvard Pilgrim Health Care, Boston, MA, USA
| | | | - Amy J Graves
- Department of Ambulatory Care and Prevention, Harvard Medical School and Harvard Pilgrim Health Care, Boston, MA, USA
| | | | - Dennis Ross-Degnan
- Department of Ambulatory Care and Prevention, Harvard Medical School and Harvard Pilgrim Health Care, Boston, MA, USA
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Madden JM, Graves AJ, Zhang F, Adams AS, Briesacher BA, Ross-Degnan D, Gurwitz JH, Pierre-Jacques M, Safran DG, Adler GS, Soumerai SB. Cost-related medication nonadherence and spending on basic needs following implementation of Medicare Part D. JAMA 2008; 299:1922-8. [PMID: 18430911 PMCID: PMC3781951 DOI: 10.1001/jama.299.16.1922] [Citation(s) in RCA: 195] [Impact Index Per Article: 12.2] [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] [Indexed: 11/14/2022]
Abstract
CONTEXT Cost-related medication nonadherence (CRN) has been a persistent problem for individuals who are elderly and disabled in the United States. The impact of Medicare prescription drug coverage (Part D) on CRN is unknown. OBJECTIVE To estimate changes in CRN and forgoing basic needs to pay for drugs following Part D implementation. DESIGN, SETTING, AND PARTICIPANTS In a population-level study design, changes in study outcomes between 2005 and 2006 before and after Medicare Part D implementation were compared with historical changes between 2004 and 2005. The community-dwelling sample of the nationally representative Medicare Current Beneficiary Survey (unweighted unique n = 24,234; response rate, 72.3%) was used, and logistic regression analyses were controlled for demographic characteristics, health status, and historical trends. MAIN OUTCOME MEASURES Self-reports of CRN (skipping or reducing doses, not obtaining prescriptions) and spending less on basic needs to afford medicines. RESULTS The unadjusted, weighted prevalence of CRN was 15.2% in 2004, 14.1% in 2005, and 11.5% after Part D implementation in 2006. The prevalence of spending less on basic needs was 10.6% in 2004, 11.1% in 2005, and 7.6% in 2006. Adjusted analyses comparing 2006 with 2005 and controlling for historical changes (2005 vs 2004) demonstrated significant decreases in the odds of CRN (ratio of odds ratios [ORs], 0.85; 95% confidence interval [CI], 0.74-0.98; P = .03) and spending less on basic needs (ratio of ORs, 0.59; 95% CI, 0.48-0.72; P < .001). No significant changes in CRN were observed among beneficiaries with fair to poor health (ratio of ORs, 1.00; 95% CI, 0.82-1.21; P = .97), despite high baseline CRN prevalence for this group (22.2% in 2005) and significant decreases among beneficiaries with good to excellent health (ratio of ORs, 0.77; 95% CI, 0.63-0.95; P = .02). However, significant reductions in spending less on basic needs were observed in both groups (fair to poor health: ratio of ORs, 0.60; 95% CI, 0.47-0.75; P < .001; and good to excellent health: ratio of ORs, 0.57; 95% CI, 0.44-0.75; P < .001). CONCLUSIONS In this survey population, there was evidence for a small but significant overall decrease in CRN and forgoing basic needs following Part D implementation. However, no net decrease in CRN after Part D was observed among the sickest beneficiaries, who continued to experience higher rates of CRN.
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Affiliation(s)
- Jeanne M Madden
- Department of Ambulatory Care and Prevention, Harvard Medical School and Harvard Pilgrim Health Care, 133 Brookline Ave, 6th Floor, Boston, Massachusetts 02215, USA.
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Graves AJ, Holmquist DR, Githens S. Effect of duct obstruction on histology and on activities of gamma-glutamyl transferase, adenosine triphosphatase, alkaline phosphatase, and amylase in rat pancreas. Dig Dis Sci 1986; 31:1254-64. [PMID: 2429807 DOI: 10.1007/bf01296529] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
The effect of pancreatic duct obstruction on the activities of amylase and three nonexocrine pancreatic enzymes was studied in the rat. gamma-Glutamyl transferase (GGTase) activity, which is localized primarily in the plasma membrane of acinar cells, disappeared from the acinar basolateral plasma membrane and declined in specific activity by 80% over a seven-day experimental period. Mg-ATPase, localized primarily in the apical plasma membrane of acinar cells, simultaneously declined in activity in acinar cells but increased in activity in connective tissue. Mg-ATPase specific activity rose 3.5-fold. The histochemical results showed that the ductlike cells resulting from obstruction were derived primarily from acinar cells. Alkaline phosphatase (APase) activity, which is localized in vascular endothelium and the stroma of interlobular ducts, exhibited a dramatic increase in the periacinar, periductal, and interlobular stroma, and specific activity rose 11-fold. Amylase-specific activity declined as did the protein to DNA ratio. Gel electrophoresis showed that the amount of zymogen granule polypeptides declined after duct obstruction, whereas a few other polypeptides increased in amount.
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