Effects of Medicare Part D medication therapy management on racial/ethnic disparities in adherence to antidementia medications among patients with Alzheimer's disease and related dementias: An observational study

Background

Evidence is sparse on the effects of Medicare medication therapy management (MTM) on racial/ethnic disparities in medication adherence among patients with Alzheimer's disease and related dementias.

Objectives

This study examined the Medicare MTM program's effects on racial/ethnic disparities in the adherence to antidementia medications among patients with Alzheimer's disease and related dementias.

Methods

This is a retrospective analysis of 100% of 2010-2017 Medicare Parts A, B, and D data linked to Area Health Resources Files. The study outcome was nonadherence to antidementia medications, and intervention was defined as new MTM enrollment in 2017. Propensity score matching was conducted to create intervention and comparison groups with comparable characteristics. A difference-in-differences model was employed with logistic regression, including interaction terms of dummy variables for the intervention group and racial/ethnic minorities.

Results

Unadjusted comparisons revealed that Black, Hispanic, and Asian/Pacific Islander patients were more likely to be nonadherent than non-Hispanic White (White) patients in 2016. Differences in odds of nonadherence between Black and White patients among the intervention group were lower in 2017 than in 2016 by 27% (odds ratios [OR]: 0.73, 95% confidence interval [CI]: 0.65-0.82). A similar lowering was seen between Hispanic and White patients by 26% (OR: 0.74, 95% CI: 0.63-0.87). MTM enrollment was associated with reduced disparities in nonadherence for Black-White patients of 33% (OR: 0.67, 95% CI: 0.57-0.78) and Hispanic-White patients of 19% (OR: 0.81, 95% CI: 0.67-0.99).

Discussion

The Medicare MTM program was associated with lower disparities in adherence to antidementia medications between Black and White patients, and between Hispanic and White patients in the population with Alzheimer's disease and related dementias.

Conclusions

Expanding the MTM program may particularly benefit racial/ethnic minorities in Alzheimer's disease and related dementia care.

[Arterial spin labeling in assessment of interstitial fibrosis in renal allografts]

Objective: To explore the feasibility and application value of arterial spin labeling (ASL) in evaluating the degree of renal fibrosis after kidney transplantation. Methods: This is a cross-sectional study. Renal transplant recipients who received treatment at the First Affiliated Hospital of Soochow University from December 2021 to December 2022 were enrolled. All participants underwent ASL scan, and the values of renal cortical renal blood flow (RBF) were measured through post-processing software. The participants were divided into different groups according to the Banff interstitial fibrosis score (ci score) of the transplanted kidneys, and then relevant indicators were compared. One-way analysis of variance was conducted to compare the differences in renal cortical RBF among the groups. Spearman correlation analysis was employed to investigate the association between renal cortical RBF and ci score of the transplanted kidney. Receiver operating characteristic curve was used to analyze the diagnostic effectiveness of renal cortical RBF and laboratory indicators for distinguishing varying degrees of fibrosis in transplanted kidneys. The Delong test was utilized to compare the area under the curve (AUC). Results: A total of 60 patients (42 males and 18 females) were included in the study, with a mean age of (44.6±10.8) years. All patients were divided into 4 groups: ci0 group (ci score=0, 11 cases), ci1 group (ci score=1, 21 cases), ci2 group (ci score=2, 20 cases), and ci3 group (ci score=3, 8 cases). With an increase in the degree of fibrosis in the transplanted kidney, there was a corresponding decrease in the renal cortical RBF value. The differences in renal cortical RBF values among the 4 groups were statistically significant[ci0 group: (214.9±28.5) ml·(100 g)-1·min-1; ci1 group: (181.7±29.3) ml·(100 g)-1·min-1; ci2 group: (158.8±39.2) ml·(100 g)-1·min-1; ci3 group: (123.1±27.2) ml·(100 g)-1·min-1; F=14.02, P<0.001]. The renal cortical RBF was moderately negatively correlated with the ci score (r=-0.644, P<0.001). The AUC for discriminating between ci0 and ci1-3 of renal cortical RBF and 24-hour urine protein was 0.881 (95%CI: 0.772-0.950) and 0.680 (95%CI: 0.547-0.795), respectively. The AUC for renal cortical RBF was significantly higher than that for 24-hour urine protein (P=0.047). The renal cortical RBF can distinguish between ci0-1 and ci2-3, as well as ci0-2 and ci3, with the corresponding AUC value of 0.796 (95%CI: 0.673-0.889) and 0.900 (95%CI: 0.795-0.963), respectively. Conclusion: ASL can quantitatively assess renal blood perfusion in transplanted kidneys and demonstrates high operational efficacy in distinguishing varying degrees of fibrosis in the transplanted kidneys.

Age-related differences in risks and outcomes of 30-day readmission in adults with sickle cell disease

BACKGROUND

Literature on 30-day readmission in adults with sickle cell disease (SCD) is limited. This study examined the overall and age-stratified rates, risk factors, and healthcare resource utilization associated with 30-day readmission in this population.

METHODS

Using the Nationwide Readmissions Database, a retrospective cohort study was conducted to identify adult patients (aged ≥ 18) with SCD in 2016. Patients were stratified by age and followed for 30 days to assess readmission following an index discharge. The primary outcome was 30-day unplanned all-cause readmission. Secondary outcomes included index hospitalization costs and readmission outcomes (e.g., time to readmission, readmission costs, and readmission lengths of stay). Separate generalized linear mixed models estimated the adjusted odds ratios (aORs) for associations of readmission with patient and hospital characteristics, overall and by age.

RESULTS

Of 15,167 adults with SCD, 2,863 (18.9%) experienced readmission. Both the rates and odds of readmission decreased with increasing age. The SCD complications vaso-occlusive crisis and end-stage renal disease (ESRD) were significantly associated with increased likelihood of readmission (p < 0.05). Age-stratified analyses demonstrated that diagnosis of depression significantly increased risk of readmission among patients aged 18-to-29 years (aOR = 1.537, 95%CI: 1.215-1.945) but not among patients of other ages. All secondary outcomes significantly differed by age (p < 0.05).

CONCLUSION

This study demonstrates that patients with SCD are at very high risk of 30-day readmission and that younger adults and those with vaso-occlusive crisis and ESRD are among those at highest risk. Multifaceted, age-specific interventions targeting individuals with SCD on disease management are needed to prevent readmissions.

Solving racial/ethnic disparities associated with Medicare Part D Star Ratings

OBJECTIVE

Medicare Part D Star Ratings are instrumental in shaping healthcare quality improvement efforts. However, the calculation metrics for medication performance measures for this program have been associated with racial/ethnic disparities. In this study, we aimed to explore whether an alternative program, named Star Plus by us that included all medication performance measures developed by Pharmacy Quality Alliance and applicable to our study population, would reduce such disparities among Medicare beneficiaries with diabetes, hypertension, and/or hyperlipidemia.

METHOD

We conducted an analysis of a 10% random sample of Medicare A/B/D claims linked to the Area Health Resources File. Multivariate logistic regressions with minority dummy variables were used to examine racial/ethnic disparities in measure calculations of Star Ratings and Star Plus, respectively.

RESULTS

Adjusted results indicated that relative to non-Hispanic Whites (Whites), racial/ethnic minorities had significantly lower odds of being included in the Star Ratings measure calculations: the odds ratios (ORs) for Blacks, Hispanics, Asians, and Others were 0.68 (95% confidence interval [CI] = 0.66-0.71), 0.73 (CI = 0.69-0.78), 0.88 (CI = 0.82-0.93), and 0.92 (CI = 0.88-0.97), respectively. In contrast, every beneficiary in the sample was included in Star Plus. Further, racial/ethnic minorities had significantly higher increase in the odds of being included in measure calculation in Star Plus than Star Ratings. The ORs for Blacks, Hispanics, Asians, and Others were 1.47 (CI = 1.41-1.52), 1.37 (CI = 1.29-1.45), 1.14 (CI = 1.07-1.22), and 1.09 (CI = 1.03-1.14), respectively.

CONCLUSIONS

Our study demonstrated that racial/ethnic disparities may be eliminated by including additional medication performance measures to Star Ratings.

Racial and ethnic disparities in the enrolment of medicare medication therapy management programs

Objectives

Racial/ethnic disparities have been found in prior literature examining enrolment in Medicare medication therapy management programs. However, those studies were based on various eligibility scenarios because enrolment data were unavailable. This study tested for potential disparities in enrolment using actual MTM enrolment data.

Methods

Medicare Parts A&B claims, Medication Therapy Management Data Files, and the Area Health Resources File from 2013 to 2014 and 2016 to 2017 were analysed in this retrospective analysis. An adjusted logistic regression compared odds of enrolment between racial/ethnic minorities and non-Hispanic Whites (Whites) in the total sample and subpopulations with diabetes, hypertension, or hyperlipidaemia. Trends in disparities were analysed by including interaction terms in regressions between dummy variables for race/ethnic minority groups and period 2016-2017.

Key Findings

Disparities in MTM enrolment were detected between Blacks and Whites with diabetes in 2013-2014 (Odds Ratio = 0.78, 95% Confidence Interval = 0.75-0.81). This disparity improved from 2013-2014 to 2016-2017 for Blacks (Odds Ratio=1.08, 95% Confidence Interval = 1.04-1.11) but persisted in 2016-2017 (Odds Ratio = 0.84, 95% Confidence Interval = 0.81-0.87). A disparity was identified between Blacks and Whites with hypertension in 2013-2014 (Odds Ratio = 0.92, 95% Confidence Interval = 0.89-0.95) but not in 2016-2017. Enrolment for all groups, however, declined between periods. For example, in the total sample, the odds of enrolment declined from 2013-2014 to 2016-2017 by 22% (Odds Ratio=0.78, 95% Confidence Interval=0.75-0.81).

Conclusions

Racial disparities in MTM enrolment were found between Blacks and Whites among Medicare beneficiaries with diabetes in both periods and among individuals with hypertension in 2013-2014. As overall enrolment fell between periods, concerns about program enrolment remain.

Telehealth Utilization in High-Risk Pregnancies During COVID-19

Purpose

To determine how telehealth has influenced outcomes in high-risk obstetrics patients during the Coronavirus disease 2019 (COVID-19) pandemic.

Methods

A retrospective chart review was conducted to identify patterns in both telehealth and in-person clinic visits among patients of a Maternal Fetal Medicine (MFM) department from the onset of the COVID-19 pandemic from March 2020 until October 2021. For the descriptive analysis, p-values were calculated using Wilcoxon rank sum for continuous variables and chi-square or Fisher exact (where cell n < 5) for categorical variables. Variables of interest were then tested for their univariate association with telehealth utilization using logistic regression. Variables found to meet the criterion of p < 0.2 in the univariate case were introduced into a multivariable logistic model with a backward elimination for determining variable retention. We aimed to analyze whether telehealth visits significantly impacted pregnancy outcomes.

Results

Four hundred nineteen high-risk patients visited the clinic via in-person and/or telehealth appointments during the study period: 320 patients without telehealth visits and 99 patients with telehealth visits. Care provided by telehealth visits was not found to be related to self-reported race (p = 0.81), maternal body mass index (p = 1.0), or maternal age (p = 0.53). Patients with private insurance were more likely to have telehealth visits than patients with public insurance (79.9% vs. 65.5%, p < 0.01). In univariate logistic analyses, patients with diagnoses of anxiety (p < 0.01), asthma (p = 0.03), and depression (p < 0.01), at the time care was established, were more likely to have telehealth visits. Those patients with telehealth visits did not have any statistical differences in mode of delivery (p = 0.2) or pregnancy outcomes (p = 0.12), including fetal demise, preterm delivery, or delivery at term as compared with patients with all in-office visits. In multivariable analysis, patient conditions of anxiety (p < 0.01), maternal obesity (p < 0.01), and twin pregnancy (p = 0.04) were associated with higher rates of telehealth visits.

Conclusion

Patients with certain pregnancy complications elected to have more telehealth visits. Patients with private insurance were more likely to have telehealth visits than patients with public insurance. There are benefits for patients with certain pregnancy complications to incorporate telehealth visits in addition to regularly scheduled in-person clinic visits and may be suitable in a post-pandemic setting as well. Further research in this field is needed to better understand the impact of implementing telehealth in high-risk obstetrics patients.

Disparities associated with Medicare Part D Star Ratings measures among patients with Alzheimer's disease and related dementias

The Medicare Parts C and D Star Ratings system was established to improve care quality in Medicare. Previous studies reported racial/ethnic disparities in the calculation of medication adherence measures of Star Ratings in patients with diabetes, hypertension, and hyperlipidemia. This study aimed to identify possible racial/ethnic disparities in the calculation of adherence measures of Medicare Part D Star Ratings among patients with Alzheimer's disease and related dementias (ADRD) and diabetes, hypertension, or hyperlipidemia. This retrospective study analyzed the 2017 Medicare data and Area Health Resources Files. Non-Hispanic White (White) patients were compared to Black, Hispanic, Asian/Pacific Islander (Asian), and other patients on their likelihood of being included in the calculation of adherence measures for diabetes, hypertension, and/or hyperlipidemia. To adjust for the individual/community characteristics, logistic regression was used when the outcome is the inclusion in the calculation of one adherence measure; multinomial regression was used when examining the inclusion in the calculation of multiple adherence measures. Analyzing the data of 1438,076 Medicare beneficiaries with ADRD, this study found that Black (adjusted odds ratio, or OR = 0.79, 95% confidence interval, or 95% CI = 0.73-0.84) and Hispanic (OR = 0.82, 95% CI = 0.75-0.89) patients were less likely than White patients to be included in the calculation of adherence measure for diabetes medications. Further, Black patients were less likely to be included in the calculation of the adherence measure for hypertension medications than White patients (OR = 0.81, 95% CI = 0.78-0.84). All minorities were less likely to be included in calculating the adherence measure for hyperlipidemia medications than Whites. The ORs for Black, Hispanic, and Asian patients were 0.57 (95% CI = 0.55-0.58), 0.69 (95% CI = 0.64-0.74), and 0.83 (95% CI = 0.76-0.91), respectively. Minority patients were generally likely to be included in the measure calculation of fewer measures than White patients. Racial/ethnic disparities were observed in the calculation of Star Ratings measures among patients with ADRD and diabetes, hypertension, and/or hyperlipidemia. Future studies should explore possible causes of and solutions to these disparities.

Cost-Effectiveness of Medication Therapy Management Program Across Racial and Ethnic Groups Among Medicare Beneficiaries

OBJECTIVES

Equity and effectiveness of the medication therapy management (MTM) program in Medicare has been a policy focus since its inception. The objective of this study was to evaluate the cost-effectiveness of the Medicare MTM program in improving medication utilization quality across racial and ethnic groups.

METHODS

This study analyzed 2017 Medicare data linked to the Area Health Recourses File. A propensity score was used to match MTM enrollees and nonenrollees, and an incremental cost-effectiveness ratio between the 2 groups was calculated. Effectiveness was measured as the proportion of appropriate medication utilization based on medication utilization measures developed by Pharmacy Quality Alliance. Net monetary benefits were compared across racial and ethnic groups at various societal willingness-to-pay (WTP) thresholds. The 95% confidence intervals were obtained by nonparametric bootstrapping.

RESULTS

MTM dominated non-MTM among the total sample (N = 699 992), as MTM enrollees had lower healthcare costs ($31 135.89 vs $32 696.69) and higher proportions of appropriate medication utilization (87.47% vs 85.31%) than nonenrollees. MTM enrollees had both lower medication costs ($10 681.21 vs $11 003.08) and medical costs ($20 454.68 vs $21 693.61) compared with nonenrollees. The cost-effectiveness of MTM was higher among Black patients than White patients across the WTP thresholds. For instance, at a WTP of $3006 per percentage point increase in effectiveness, the net monetary benefit for Black patients was greater than White patients by $2334.57 (95% confidence interval $1606.53-$3028.85).

CONCLUSIONS

MTM is cost-effective in improving medication utilization quality among Medicare beneficiaries and can potentially reduce disparities between Black and White patients. Expansion of the current MTM program could maximize these benefits.

Racial and ethnic disparities in Medicare Part D medication therapy management services utilization

Background

The Medicare Part D medication therapy management (MTM) program has positive effects on medication and health service utilization. However, little is known about its utilization, much less so about the use among racial and ethnic minorities.

Objective

To examine MTM service utilization among older Medicare beneficiaries and to identify any racial and ethnic disparity patterns.

Methods

A retrospective cross-sectional analysis of 2017 Medicare administrative data, linked to the Area Health Resources Files. Fourteen outcomes related to MTM service nature, initiation, quantity, and delivery were examined using logistic, negative binomial, and Cox proportional hazards regression models.

Results

Racial and ethnic disparities were found with varying patterns across outcomes. For example, compared with White patients, the odds of opting out of MTM were 8% higher for Black patients (odds ratio [OR] = 1.08, 95% confidence interval [CI] = 1.03-1.14), 57% higher for Hispanic patients (OR = 1.57, 95% CI = 1.42-1.72), and 57% higher for Asian patients (OR = 1.57, 95% CI = 1.33-1.85). The odds of continuing MTM from the previous years were 12% lower for Black patients (OR = 0.88, 95% CI = 0.86-0.90) and 3% lower for other patients (OR = 0.97, 95% CI = 0.95-0.99). In addition, the probability of being offered a comprehensive medication review (CMR) after MTM enrollment was 9% lower for Hispanic patients (hazard ratio [HR] = 0.91, 95% CI = 0.85-0.97), 9% lower for Asian patients (HR = 0.91, 95% CI = 0.87-0.94), and 3% lower for other patients (HR = 0.97, 95% CI = 0.95-0.99). Hispanic and Asian patients were more likely to have someone other than themselves receive a CMR.

Conclusions

Racial and ethnic disparities in MTM service utilization were identified. Although the disparities in specific utilization outcomes vary across racial/ethnic groups, it is evident that these disparities exist and may result in vulnerable communities not fully benefiting from the MTM services. Causes of the disparities should be explored to inform future reform of the Medicare Part D MTM program.

Racial/ethnic disparities in the enrollment of Medication Therapy Management programs among Medicare beneficiaries with Alzheimer's disease and related dementias

OBJECTIVE

Previous analysis of policy scenarios reported potential disparities in eligibility in the Medicare Medication Therapy Management (MTM) program. With recently released MTM data, this study aimed to determine if racial/ethnic disparities exist in MTM enrollment among Medicare beneficiaries with Alzheimer's disease and related dementias (ADRD).

METHODS

Medicare claims/records (from 2013-2014 and 2016-2017) linked to the Area Health Resources File were examined. Included individuals were patients with ADRD and diabetes, hypertension or hyperlipidemia. The proportions of MTM enrollment were compared between non-Hispanic White (White) patients and racial/ethnic minority groups in descriptive analysis. Racial/ethnic disparities were then examined using a logistic regression adjusting for patient and community characteristics. Disparities across study periods were compared by estimating a logistic regression model with interaction terms between dummy variables for each racial/ethnic minority group and 2016-2017.

RESULTS

In unadjusted analyses, minorities had higher enrollment proportions than Whites. In 2016-2017, for example, enrollment percentages for Whites, Blacks, Hispanics, Asian/Pacific Islanders (Asians) and Others were respectively 14.44%, 16.71%, 19.83%, 16.66%, and 17.78%. In adjusted analyses, Blacks had lower enrollment odds than Whites within all cohorts. In the entire study sample in 2016-2017, for example, Blacks with ADRD had 9% lower odds of MTM enrollment (odds ratio 0.91, 95% confidence interval [CI] = 0.86-0.97) than Whites. These disparities decreased over time among the ADRD sample and all sub-groups. The interaction term between Blacks and 2016-2017, for instance, indicated that disparities were lowered by 11% (odds ratio 1.11, 95% CI = 1.05-1.16) across study periods among those with ADRD.

CONCLUSIONS

Blacks with ADRD, and diabetes, hypertension or hyperlipidemia have lower likelihood of MTM enrollment than Whites. Racial disparities were reduced over time but not eliminated.

Effects of Medicare comprehensive medication review on racial/ethnic disparities in nonadherence to statin medications among patients with Alzheimer's Disease: an observational analysis

Background

Alzheimer’s Disease (AD) is the mostcommon cause of dementia, a neurological disorder characterized by memory loss and judgment impairment. Hyperlipidemia, a commonly co-occurring condition, should be treated to prevent associated complications. Medication adherence may be difficult for individuals with AD due to the complexity of AD management. Comprehensive Medication Reviews (CMRs), a required component of Medicare Part D Medication Therapy Management (MTM), have been shown to improve medication adherence. However, many MTM programs do not target AD. Additionally, racial/ethnic disparities in MTM eligibility have been revealed. Thus, this study examined the effects of CMR receipt on reducing racial/ethnic disparities in the likelihood of nonadherence to hyperlipidemia medications (statins) among the AD population.

Methods

This retrospective study used 2015-2017 Medicare data linked to the Area Health Resources Files. The likelihood of nonadherence to statin medications across racial/ethnic groups was compared between propensity-score-matched CMR recipients and non-recipients in a ratio of 1 to 3. A difference-in-differences method was utilized to determine racial/ethnic disparity patterns using a logistic regression by including interaction terms between dummy variables for CMR receipt and each racial/ethnic minority group (non-Hispanic Whites, or Whites, as reference).

Results

The study included 623,400 Medicare beneficiaries. Blacks and Hispanics had higher statin nonadherence than Whites: Compared to Whites, Blacks’ nonadherence rate was 4.53% higher among CMR recipients and 7.35% higher among non-recipients; Hispanics’ nonadherence rate was 2.69% higher among CMR recipients and 7.38% higher among non-recipients. Differences in racial/ethnic disparities between CMR recipients and non-recipients were significant for each minority group (p < 0.05) except Others. The difference between Whites and Hispanics in the odds of statin nonadherence was 11% lower among CMR recipients compared to non-recipients (OR = 0.89; 95% Confidence Interval = 0.85-0.94 for the interaction term between dummy variables for CMR and Hispanics). Interaction terms between dummy variables for CMR and other racial/ethnic minorities were not significant.

Conclusions

Receiving a CMR was associated with a disparity reduction in nonadherence to statin medications between Hispanics and Whites among patients with AD. Strategies need to be explored to increase the number of MTM programs that target AD and promote CMR completion.

Democracy and case fatality rate of COVID-19 at early stage of pandemic: a multicountry study

Many studies have evaluated factors that influence the course of the COVID-19 pandemic in different countries. This multicountry study assessed the influence of democracy and other factors on the case fatality rate of COVID-19 during the early stage of the pandemic. We accessed the World Health Organization, World Bank, and the Democracy Index 2019 databases for data from the 148 countries. Multiple analyses were conducted to examine the association between the Democracy Index and case fatality rate of COVID-19. Within 148 countries, the percentage of the population aged 65 years and above (p = 0.0193), and health expenditure as a percentage of GDP (p = 0.0237) were positively associated with countries' case fatality rates. By contrast, hospital beds per capita helped to reduce the case fatality rates. In particular, the Democracy Index was positively associated with case fatality rates in a subgroup of 47 high-income countries. This study suggests that enhancing the health system with increased hospital beds and healthcare workforce per capita should reduce case fatality rate. The findings suggest that a higher Democracy Index is associated with more deaths from COVID-19 at the early stage of the pandemic, possibly due to the decreased ability of the government.

Survival Benefit Associated With the Use of Extracorporeal Life Support for Neonates With Congenital Diaphragmatic Hernia

OBJECTIVE

To measure the survival among comparable neonates with CDH supported with and without ECLS.

SUMMARY OF BACKGROUND DATA

Despite widespread use in the management of newborns with CDH, ECLS has not been consistently associated with improved survival.

METHODS

A retrospective cohort study was performed using ECLS-eligible CDH Study Group registry patients born between 2007 and 2019. The primary outcome was in-hospital mortality. Neonates who did and did not receive ECLS were matched based on variables affecting risk for the primary outcome. Iterative propensity score-matched, survival (Cox regression and Kaplan-Meier), and center effects analyses were performed to examine the association of ECLS use and mortality.

RESULTS

Of 5855 ECLS-eligible CDH patients, 1701 (29.1%) received ECLS. "High-risk" patients were best defined as those with a lowest achievable first-day arterial partial pressure of CO2 of ≥60 mm Hg. After propensity score matching, mortality was higher with ECLS (47.8% vs 21.8%, odds ratio 3.3, 95% confidence interval 2.7-4.0, hazard ratio 2.3, P < 0.0001). For the subgroup of high-risk patients, there was lower mortality observed with ECLS (64.2% vs 84.4%, odds ratio 0.33, 95% confidence interval 0.17-0.65, hazard ratio 0.33, P = 0.001). This survival advantage was persistent using multiple matching approaches. However, this ECLS survival advantage was found to occur primarily at high CDH volume centers that offer frequent ECLS for the high-risk subgroup.

CONCLUSIONS

Use of ECLS is associated with excess mortality for low- and intermediate-risk neonates with CDH. It is associated with a significant survival advantage among high-risk infants, and this advantage is strongly influenced by center CDH volume and ECLS experience.

Effects of the Medicare Part D comprehensive medication review on medication adherence among patients with Alzheimer's disease

OBJECTIVE

Older patients with Alzheimer's disease (AD) are challenged with adhering to complex medication regimens. We examined effects of Comprehensive Medication Review (CMR), a required Medicare Part D Medication Therapy Management (MTM) program component, on medication adherence among AD patients.

METHODS

This retrospective study analyzed 100% of 2016-2017 Medicare claims covering the entire United States, linked to Area Health Resources Files. Medicare beneficiaries aged ≥65 years were included. Propensity score matching identified comparable intervention and comparison groups with the intervention defined as receiving a CMR in 2017. A difference-in-differences analysis included in multivariate logistic regressions an interaction term between CMR receipt and year 2017. The outcome measured was nonadherence to diabetes, hypertension and hyperlipidemia medications, with nonadherence defined as proportion of days covered <80% for study medications.

RESULTS

Unadjusted comparisons indicated the proportion of nonadherence for intervention group members decreased from 2016 to 2017 but increased for the comparison group. In adjusted analyses, reduction in medication nonadherence among the intervention group remained higher: odds ratios for the interaction term were 0.62 (95% confidence interval [CI] = 0.54-0.71), 0.54 (95% CI = 0.50-0.58) and 0.50 (95% CI = 0.47-0.53) respectively for diabetes, hypertension and hyperlipidemia medications. This suggests that the likelihood of nonadherence in the intervention group was respectively reduced by 38%, 46% and 50% more than the comparison group.

CONCLUSIONS

CMR was found to reduce nonadherence to diabetes, hypertension and hyperlipidemia medications among older Medicare beneficiaries with AD. This provides evidence that the MTM program is effective for a population with unique medication compliance challenges.

Effects of the Medicare Part D Comprehensive Medication Review on Racial and Ethnic Disparities in Medication Adherence

BACKGROUND

Substantial research has documented inequalities between US minorities and whites in meeting the eligibility criteria for the Medicare Part D medication therapy management (MTM) program. Even though the Centers for Medicare & Medicaid Services attempted to relax the eligibility criteria, a critical barrier to effective MTM reform is a lack of stronger evidence about the effects of MTM on minorities' health outcomes.

OBJECTIVE

To examine the effects of comprehensive medication review (CMR), an MTM core component, on racial and ethnic disparities in adherence to diabetes, hypertension, and hyperlipidemia medications among Medicare beneficiaries aged ≥65 years.

METHODS

This study used full-year 2017 Medicare Parts A, B, and D claims data, including MTM data, linked to the Area Health Resources Files. Racial and ethnic disparities in nonadherence to diabetes, hypertension, and hyperlipidemia medications were compared between CMR recipients and nonrecipients matched by their propensity scores. To determine the changes in racial and ethnic disparities after receiving CMR, a difference-in-differences framework was applied, by including in logistic regression analyses interaction terms between dummy variables for CMR receipt and each racial or ethnic minority group.

RESULTS

Compared with CMR nonrecipients, CMR recipients had significantly lower racial and ethnic disparities across the 3 outcome measures, with the exception of the difference between whites and blacks in nonadherence to diabetes medications. For example, compared with CMR nonrecipients, among CMR recipients the differences in the odds of nonadherence to hypertension medications were reduced, respectively, by 8% (95% confidence interval [CI], 0.88-0.96) between whites and blacks; by 18% (95% CI, 0.78-0.86) between whites and Hispanics; by 16% (95% CI, 0.77-0.91) between whites and Asians; and by 9% (95% CI, 0.85-0.98) between whites and other racial and ethnic groups.

CONCLUSION

Receiving a CMR reduced the racial and ethnic disparities in adherence to diabetes, hypertension, and hyperlipidemia medications among Medicare beneficiaries aged ≥65 years. These findings provide critical empirical evidence that may inform the future design of the Medicare Part D MTM program, which is valuable for improving pharmacotherapy outcomes and could further realize its potential when additional people from racial and ethnic minorities are enrolled.

Exploring racial and ethnic disparities in medication adherence among Medicare comprehensive medication review recipients

Background

There has been a lack of evidence on whether there are racial and ethnic disparities in medication nonadherence among individuals receiving comprehensive medication review (CMR), a required component of the Medicare Part D medication therapy management (MTM) services.

Objectives

To explore racial/ethnic disparities in medication nonadherence among older MTM enrollees who received a CMR and to determine how much the identified disparities can be explained by observed characteristics.

Methods

The retrospective study used 100% of the 2017 Medicare claims, including MTM data. Linked Area Health Resources Files provided community characteristics. Nonadherence was defined as proportion of days covered <80%, and was measured for diabetes, hypertension, and hyperlipidemia medications. Racial/ethnic disparities were examined by logistic regressions that included racial/ethnic minority dummy variables. A nonlinear Blinder-Oaxaca decomposition method was applied to decompose the identified disparities.

Results

Compared with non-Hispanic Whites (Whites), Blacks were respectively 39% (odds ratio [OR] = 1.39, 95% confidence interval [CI] = 1.33–1.45), 27% (OR = 1.27, 95% CI = 1.22–1.32), and 43% (OR = 1.43, 95% CI = 1.39–1.47) more likely to be nonadherent to diabetes, hypertension, and hyperlipidemia medications; Hispanics were 20% (OR = 1.20, 95% CI = 1.14–1.27) more likely to be nonadherent to hyperlipidemia medications. The total portion of disparity explained was 13.42%, 7.66%, 14.87%, and 10.69% respectively for disparities in Black-White (B–W) diabetes, B–W hypertension, B–W hyperlipidemia, and Hispanic-White hyperlipidemia. The top three contributors were the proportion of married-couple families, census region, and male gender.

Conclusions

A lower level of community affluence and social support, regional variations, and a lower proportion of males in Blacks and Hispanics may contribute to the disparities in medication nonadherence. The large unexplained portion of the disparity attests that nonadherence is a complex issue. The Medicare MTM program needs to implement measures to reduce disparities in medication adherence.

•

This retrospective study used 100% of the 2017 Medicare claims including MTM data.

•

Racial/ethnic disparity in medication adherence was identified among CMR recipients.

•

Blacks were more likely than Whites to be nonadherent to all medications studied.

•

Hispanics were more likely than Whites to be hyperlipidemia medication nonadherent.

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Observed characteristics explained close to 15% of the identified disparity.

Racial/ethnic disparities in measure calculations for Part D Star Ratings among Medicare beneficiaries with diabetes, hypertension, and/or hyperlipidemia

BACKGROUND

Previous literature reported racial/ethnic disparities in the measure assessment of diabetes medication adherence in the Medicare Part D Star Ratings program.

OBJECTIVE

This study examined the likelihood of inclusion in measure calculation across racial/ethnic groups for adherence metrics in Part D Star Ratings among individuals with diabetes, hypertension, and/or hyperlipidemia.

METHODS

This was a retrospective cross sectional analysis of a 10% random sample of 2017 Medicare claims linked to Area Health Resources Files. Inclusion in measure calculation was determined based on inclusion/exclusion criteria in adherence metrics for adherence medications for diabetes, hypertension, and hyperlipidemia in Part D Star Ratings developed by the Pharmacy Quality Alliance. Logistic regression and multinomial logistic regression were used to adjust for patient/community characteristics.

RESULTS

The study sample size was 2 707 216. Compared to Non-Hispanic White (White) beneficiaries, minorities were more likely to be excluded from measure calculation among individuals with 1 condition. For example, among individuals with hypertension, compared to White individuals, the adjusted odds ratios for exclusion for Black, Hispanic, Asian/Pacific Islander and other individuals were 1.46 (95% confidence interval, or CI = 1.42-1.50), 1.38 (95% CI = 1.33-1.43), 1.28 (95% CI = 1.21-1.35), and 1.08 (95% CI = 1.02-1.15), respectively. Among individuals with more than 1 chronic condition, minorities were more likely to be included in fewer calculations for medication adherence measures. For example, among individuals with all 3 conditions, the adjusted relative risk ratios for Black, compared to White, beneficiaries for being included in 0, 1, and 2 measures, versus all 3 measures, were 2.14 (95% CI = 1.99-2.30), 1.49 (95% CI = 1.41-1.56), 1.20 (95% CI = 1.18-1.23), respectively.

CONCLUSIONS

Compared to White beneficiaries, racial/ethnic minorities are more likely to be excluded from the calculation for adherence measures among individuals with diabetes, hypertension, and/or hyperlipidemia. Future studies should examine whether such disparities exacerbate existing racial/ethnic disparities in health outcomes and devise solutions for these disparities.

Medication nonadherence, mental health, opioid use, and inpatient and emergency department use in super-utilizers

OBJECTIVES

To examine whether mental health conditions, opioid use, and medication nonadherence are associated with inpatient and emergency department (ED) use among Medicare super-utilizers from medically underserved areas.

STUDY DESIGN

Retrospective panel study.

METHODS

The study included Medicare super-utilizers (≥3 hospitalizations or ≥2 hospitalizations with ≥2 ED visits in 6 months) served by a health system in a medically underserved area in the South from February 2013 to December 2014 with at least 1 filled prescription for hypertension, type 2 diabetes, cardiovascular, and/or chronic obstructive pulmonary disease/asthma medications. We used random effects negative binomial models to assess whether mental health diagnosis, opioid use, and medication nonadherence were associated with preventable and overall hospitalizations and ED visits stratified by age (18-64 vs ≥65 years).

RESULTS

Overall chronic disease medication nonadherence was associated with more frequent hospitalizations and ED visits for both younger (hospitalizations: incidence rate ratio [IRR], 1.31; 95% CI, 1.16-1.47; ED visits: IRR, 1.33; 95% CI, 1.14-1.55) and older (hospitalizations: IRR, 1.34; 95% CI, 1.20-1.49; ED visits: IRR, 1.18; 95% CI, 1.02-1.38) beneficiaries. Mental health diagnosis was significantly associated with higher hospitalizations and ED visits among both age groups. Although associations between opioid medication use and inpatient and ED use were inconsistent and not significant in most cases, we found that 7 or more days' supply of opioids was associated with lower preventable hospitalizations in Medicare beneficiaries 65 years or older.

CONCLUSIONS

The study findings highlight the importance of improving medication adherence and addressing behavioral health needs in Medicare super-utilizers.

The effect of current and former tobacco use on outcomes after primary reverse total shoulder arthroplasty

BACKGROUND

The purpose of this study was to determine the influence of current and former tobacco use on minimum 2-year clinical and radiographic outcomes after reverse total shoulder arthroplasty (RTSA).

METHODS

Review of primary RTSA patient data identified 186 patients with at least 2 years of follow-up. Patients were classified as nonsmokers (76 patients), former smokers (89 patients), or current smokers (21 patients). Assessment included preoperative and postoperative visual analog scale pain scores, American Shoulder and Elbow Surgeons scores, strength, range of motion, complications, revisions, and narcotic use. Radiographs were analyzed for signs of loosening or mechanical failure.

RESULTS

Overall mean age of the patients was 70 (48-87) years, and mean follow-up was 2.6 (2.0-5.7) years. Smokers (62.1 years) were significantly younger than nonsmokers (70.7 years) and former smokers (70.8 years; P = .00002). All patients had significant improvements in pain, American Shoulder and Elbow Surgeons score, strength, and forward flexion range of motion; however, smokers had higher visual analog scale pain scores (mean, 2.5) than nonsmokers (mean, 1.8) or former smokers (mean, 1.0; P = .014). Otherwise, no differences were found regarding any of the postoperative parameters (P > .05).

CONCLUSIONS

Aside from increased patient-reported pain, current tobacco use does not appear to negatively affect outcomes after primary RTSA. The RTSA design obviates the need for a functioning rotator cuff, possibly mitigating tobacco's negative effects previously demonstrated in rotator cuff repair and anatomic total shoulder arthroplasty. Former users obtained outcomes similar to those of nonusers, suggesting that tobacco use is a modifiable risk factor to achieve optimal pain relief after RTSA.

Elevated Serum α-Fetoprotein is Associated with Abbreviated Survival for Patients with Fibrolamellar Hepatocellular Carcinoma Who Undergo a Curative Resection

BACKGROUND

Fibrolamellar hepatocellular carcinoma (FLC) is a rare variant of hepatocellular carcinoma (HCC), with most clinical data stemming from single-institution series. The variability in the literature lends support for analysis using a large national dataset. In doing so, we sought to (1) define the characteristics and outcomes of patients with FLC; (2) determine factors associated with survival in patients undergoing resection; and (3) compare the overall survival (OS) of patients with FLC with a matched group of patients with HCC.

METHODS

The National Cancer Database was queried for patients with FLC, and their clinicopathologic features were recorded. Univariate and multivariate analyses were performed to delineate factors associated with survival.

RESULTS

Between 2004 and 2015, 496 patients were diagnosed with FLC, 229 of whom underwent a curative resection. The median OS for patients with FLC undergoing curative resection was 78.5 months. Factors associated with abbreviated OS in this surgical cohort include multiple tumors [hazard ratio (HR) 3.15, p = 0.025], positive regional lymph nodes (HR 2.83, p = 0.023), and elevated serum α-fetoprotein (AFP; HR 2.81, p = 0.034). When the OS of patients with FLC was compared with a matched group of patients with HCC, no difference was detected (p = 0.748); however, patients with FLC and elevated AFP had abbreviated OS compared with patients with HCC and elevated AFP (43 vs. 82 months, p ≤ 0.001).

CONCLUSIONS

Elevations in serum AFP occur more frequently than previously documented for patients with FLC and are associated with abbreviated OS. AFP levels may help guide the decision for operative intervention in patients with FLC.

Resection and chemotherapy is the optimal treatment approach for patients with clinically node positive intrahepatic cholangiocarcinoma

BACKGROUND

Clinically lymph node positive (cLNP) intrahepatic cholangiocarcinoma (ICC) carries a poor prognosis, without clear management guidelines for the practicing clinician. We sought to evaluate current practice patterns for cLNP ICC, including associations with survival.

METHODS

The National Cancer Database was queried for patients with cLNP ICC, without extrahepatic metastases.

RESULTS

We identified 1023 patients with cLNP ICC, 77%% (n = 784) of whom received chemotherapy alone. Resection was undertaken in 23% (n = 239) of patients and was most commonly utilized in combination with chemotherapy (n = 150). Median survival for all patients was 13.6 months. Patients undergoing resection in combination with chemotherapy were associated with an improved survival (22.5 months) as compared to those patients receiving chemotherapy alone (11.9 months) or resection alone (12.4 months) (p < 0.01). Finally, we compared the survival of patients with cLNP ICC with that of patients with pathologically proved lymph node positive (pLNP) ICC, all of whom were treated with resection with chemotherapy, and found no difference in survival (22.5 months-19.3 months, p = 0.99, respectively).

CONCLUSIONS

While the decision to pursue resection for ICC is multifactorial and patient specific, the presence of clinically positive LNs should not represent a contraindication.

Effect of Intensive Interdisciplinary Transitional Care for High-Need, High-Cost Patients on Quality, Outcomes, and Costs: a Quasi-Experimental Study

BACKGROUND

Many health systems have implemented team-based programs to improve transitions from hospital to home for high-need, high-cost patients. While preliminary outcomes are promising, there is limited evidence regarding the most effective strategies.

OBJECTIVE

To determine the effect of an intensive interdisciplinary transitional care program emphasizing medication adherence and rapid primary care follow-up for high-need, high-cost Medicaid and Medicare patients on quality, outcomes, and costs.

DESIGN

Quasi-experimental study.

PATIENTS

Among 2235 high-need, high-cost Medicare and Medicaid patients identified during an index inpatient hospitalization in a non-profit health care system in a medically underserved area with complete administrative claims data, 285 participants were enrolled in the SafeMed care transition intervention, and 1950 served as concurrent controls.

INTERVENTIONS

The SafeMed team conducted hospital-based real-time screening, patient engagement, enrollment, enhanced discharge care coordination, and intensive home visits and telephone follow-up for at least 45 days.

MAIN MEASURES

Primary difference-in-differences analyses examined changes in quality (primary care visits, and medication adherence), outcomes (preventable emergency visits and hospitalizations, overall emergency visits, hospitalizations, 30-day readmissions, and hospital days), and medical expenditures.

KEY RESULTS

Adjusted difference-in-differences analyses demonstrated that SafeMed participation was associated with 7% fewer hospitalizations (- 0.40; 95% confidence interval (CI), - 0.73 to - 0.06), 31% fewer 30-day readmissions (- 0.34; 95% CI, - 0.61 to - 0.07), and reduced medical expenditures ($- 8690; 95% CI, $- 14,441 to $- 2939) over 6 months. Improvements were limited to Medicaid patients, who experienced large, statistically significant decreases of 39% in emergency department visits, 25% in hospitalizations, and 79% in 30-day readmissions. Medication adherence was unchanged (+ 2.6%; 95% CI, - 39.1% to 72.9%).

CONCLUSIONS

Care transition models emphasizing strong interdisciplinary patient engagement and rapid primary care follow-up can enable health systems to improve quality and outcomes while reducing costs among high-need, high-cost Medicaid patients.

Proteomic Profiling of Exosomes Derived from Plasma of HIV-Infected Alcohol Drinkers and Cigarette Smokers

Abuse of alcohol and tobacco could exacerbate HIV pathogenesis by transferring materials through exosomes (small nanovesicles). Exosomes present a stable and accessible source of information concerning the health and/or disease status of patients, which can provide diagnostic and prognostic biomarkers for myriad conditions. Therefore, we aimed to study the specific exosomal proteins that are altered in both HIV-infected subjects and alcohol/tobacco users. Exosomes were isolated from plasma of the following subjects: a) HIV-negative subjects (healthy), b) HIV-positive subjects (HIV), c) HIV-negative alcohol drinkers (drinkers), d) HIV-negative tobacco smokers (smokers), e) HIV-positive drinkers (HIV + drinkers), and f) HIV-positive smokers (HIV + smokers). Quantitative proteomic profiling was then performed from these exosomes. Sixteen proteins were significantly altered in the HIV group, ten in drinkers, four in HIV + drinkers, and fifteen in smokers compared to healthy subjects. Only one protein, fibulin-1 (FBLN1), was significantly altered in HIV + smokers. Interestingly, hemopexin was not significantly altered in drinkers or HIV patients but was significantly altered in HIV + drinkers. Further, our study is the first to show properdin expression in plasma exosomes, which was decreased in HIV + smokers and HIV + drinkers compared to HIV patients. The present findings suggest that hemopexin and properdin show potential as markers for physiological effects that may arise in HIV-infected individuals who abuse alcohol and tobacco. Graphical abstract This study presents a proteomic analysis of plasma-derived exosomes from HIV-infected alcohol drinkers and smokers. Among the proteins altered due to drug-abuse, hemopexin and properdin were of highest significance. These proteins can be potential biomarkers for co-morbid conditions associated with drug abuse in HIV-patients.

Predictive Value Positive of MTM Eligibility Criteria under MMA and ACA in Identifying Individuals with Medication Utilization Issues

Objectives

To compare the predictive value positives (PVP) of medication therapy management eligibility criteria under the Medicare Modernization Act (MMA) and Affordable Care Act (ACA) in identifying individuals with medication utilization issues (MUI).

Methods

This is a retrospective analysis of Medicare database (2012-2013). MUI were determined based on medication utilization measures related to Medicare Part D Star Ratings. PVP or proportions of individuals with MUI were compared between individuals eligible for MTM under MMA and ACA. Need-based and demand-based logistic regression was used to adjust for patient characteristics. MTM eligibility thresholds in 2009 and 2013 and proposed 2015 MTM eligibility thresholds under MMA were examined. Main/sensitivity/disease-specific analyses were conducted to cover the range of eligibility thresholds and combinations.

Key Findings

MMA has higher PVP in identifying patients with MUI than ACA. Proportions of individuals with MUI were higher based on MMA than ACA (e.g., 74.96% for 2009 MMA, 73.51% for 2013 MMA, and 62.46% for proposed 2015 MMA vs. 52.17% for ACA in main analysis; P<0.05). Adjusted findings were similar. For example, based on the demand-based model in the main analysis, the odds ratios were 2.474 (95% CI: 2.454-2.494) for 2013 MMA in comparison to ACA. These numbers indicate that the MMA MTM eligibility criteria for 2013 had 147.4% higher PVP in identifying patients with MUI than ACA. Similar patterns were found in most sensitivity and disease-specific analyses.

Conclusions

MMA has higher PVP than ACA in identifying patients with MUI. This study may inform the government on future MTM policy.

Laparoscopic Approach to Intrahepatic Cholangiocarcinoma is Associated with an Exacerbation of Inadequate Nodal Staging

INTRODUCTION

Laparoscopic approach to liver resection is feasible and safe, though its utilization with intrahepatic cholangiocarcinoma (ICC) remains poorly documented. We sought to evaluate the use laparoscopy for ICC, and to examine adherence to oncologic standards.

METHODS

The National Cancer Database was queried for patients who underwent resection for ICC. Patients were stratified by laparoscopic (LLR) versus open liver resection (OLR). Clinicopathologic parameters and hospital volumes were recorded.

RESULTS

In total, 2309 patients with ICC underwent hepatic resection (1997 OLR, 312 LLR) between 2010 and 2015. LLR increased from 12 to 16% during the study period and was utilized more commonly than OLR for wedge and segmental resections (56% vs. 33%, p < 0.001). Nodal evaluation was performed in 58% of all patients with ICC and was significantly more common in patients undergoing OLR (61%, n = 1210) versus LLR (39%, n = 120), p < 0.001. Of the 120 patients undergoing LLR with any nodal evaluation, 31% (n = 37) had a single node evaluated. Patients who underwent LLR were less likely to have ≥ 6 lymph nodes evaluated compared with those who underwent OLR (9% vs. 15%, respectively, p < 0.001).

CONCLUSIONS

The use of laparoscopy for ICC is associated with an exacerbation of inadequate nodal evaluation compared with open resections.

Comparative Effectiveness of Medication Therapy Management Eligibility Criteria Across Racial/Ethnic Groups

BACKGROUND/OBJECTIVES

Previous research indicates that eligibility criteria for medication therapy management (MTM) services in Medicare prescription drug (Part D) plans, defined under the Medicare Modernization Act (MMA), are associated with racial/ethnic disparities and ineffective in identifying individuals with medication utilization issues. Our study's objective was to determine the comparative effectiveness of MTM eligibility criteria under MMA and in the Affordable Care Act (ACA) in identifying patients with medication utilization issues across racial/ethnic groups.

DESIGN

ACA and MMA MTM eligibility criteria were compared on proportions of eligible individuals among patients with medication utilization issues. Multinomial logistic regression was conducted to control for patient/community characteristics. Need-based and demand-based analyses were used to determine disparities due to need and demand for healthcare. Main/sensitivity analyses were conducted for the range of eligibility thresholds.

SETTING

Medicare data (2012-2013) linked to Area Health Resources Files.

PARTICIPANTS

A total of 964 610 patients 65 years or older.

MEASUREMENTS

Medication safety/adherence measures, developed primarily by the Pharmacy Quality Alliance, were used to determine medication utilization issues.

RESULTS

Higher proportions of patients were eligible based on ACA than MMA MTM eligibility criteria. For example, in 2013, proportions based on ACA and MMA MTM eligibility criteria would be 99.7% and 26.2%, respectively, in the main analysis (p < .001); in the demand-based main analysis, ACA criteria were associated with 13.6% and 9.8%, respectively, higher effectiveness than MMA criteria among non-Hispanic blacks and Hispanics than non-Hispanic whites.

CONCLUSION

ACA MTM eligibility criteria are more effective than MMA criteria in identifying older patients needing MTM, particularly among minorities. J Am Geriatr Soc 67:581-587, 2019.

Higher Predictive Value Positive for MMA Than ACA MTM Eligibility Criteria Among Racial and Ethnic Minorities: An Observational Study

The objective of this study was to examine positive predictive value (PPV) of medication therapy management (MTM) eligibility criteria under Medicare Modernization Act (MMA) and Affordable Care Act (ACA) in identifying patients with medication utilization issues across racial and ethnic groups. The study analyzed Medicare data (2012-2013) for 2 213 594 beneficiaries. Medication utilization issues were determined based on medication utilization measures mostly developed by Pharmacy Quality Alliance. MMA was associated with higher PPV than ACA in identifying individuals with medication utilization issues among non-Hispanic blacks (blacks) and Hispanics than non-Hispanic whites (whites). For example, odds ratio for having medication utilization issues to whites when examining MMA in 2013 and ACA were 1.09 (95% confidence interval [CI] = 1.04-1.15) among blacks, and 1.17 (95% CI = 1.10-1.24) among Hispanics, in the main analysis. Therefore, MMA was associated with 9% and 17% higher PPV than ACA in identifying patients with medication utilization issues among blacks and Hispanics, respectively, than whites.

Clinical significance of MUC13 in pancreatic ductal adenocarcinoma

BACKGROUND

Poor prognosis of pancreatic cancer (PanCa) is associated with lack of an effective early diagnostic biomarker. This study elucidates significance of MUC13, as a diagnostic/prognostic marker of PanCa.

METHODS

MUC13 was assessed in tissues using our in-house generated anti-MUC13 mouse monoclonal antibody and analyzed for clinical correlation by immunohistochemistry, immunoblotting, RT-PCR, computational and submicron scale mass-density fluctuation analyses, ROC and Kaplan Meir curve analyses.

RESULTS

MUC13 expression was detected in 100% pancreatic intraepithelial neoplasia (PanIN) lesions (Mean composite score: MCS = 5.8; AUC >0.8, P < 0.0001), 94.6% of pancreatic ductal adenocarcinoma (PDAC) samples (MCS = 9.7, P < 0.0001) as compared to low expression in tumor adjacent tissues (MCS = 4, P < 0.001) along with faint or no expression in normal pancreatic tissues (MCS = 0.8; AUC >0.8; P < 0.0001). Nuclear MUC13 expression positively correlated with nodal metastasis (P < 0.05), invasion of cancer to peripheral tissues (P < 0.5) and poor patient survival (P < 0.05; prognostic AUC = 0.9). Submicron scale mass density and artificial intelligence based algorithm analyses also elucidated association of MUC13 with greater morphological disorder (P < 0.001) and nuclear MUC13 as strong predictor for cancer aggressiveness and poor patient survival.

CONCLUSION

This study provides significant information regarding MUC13 expression/subcellular localization in PanCa samples and supporting the use anti-MUC13 MAb for the development of PanCa diagnostic/prognostic test.

The impact of unplanned conversion to an open procedure during minimally invasive pancreatectomy

BACKGROUND

Minimally invasive pancreatic resection (MIPR) is being increasingly utilized. Outcomes for patients experiencing unplanned conversion to an open procedure during MIPR have been incompletely assessed. We sought to determine the short-term outcomes and factors associated with unplanned conversion during MIPR.

METHODS

A retrospective cohort study using the American College of Surgeons National Surgical Quality Improvement Program pancreatectomy-targeted data set was conducted. Successful MIPR was compared with unplanned conversion. Propensity matching was used to separately compare unplanned conversion during MIPR with planned open pancreatectomy.

RESULTS

Unplanned conversion occurred in 24.6% of 350 attempted minimally invasive pancreatoduodenectomy (MIPD) and 19.6% of 1174 attempted minimally invasive distal pancreatectomy (MIDP). Conversion was associated with greater overall morbidity and 30-day mortality compared with successful MIPR for both MIPD and MIDP. After matching, unplanned conversion resulted in outcomes equivalent or inferior to open pancreatectomy. Factors significantly associated with unplanned conversion during MIPD included intermediate gland texture, vascular resection, hypertension, disseminated cancer, and chronic steroid use. For MIDP, male sex, hard gland texture, vascular resection, smoking, and recent weight loss were independently associated with conversion. A robotic approach was inversely associated with conversion for MIPD and MIDP.

CONCLUSIONS

Unplanned conversion during MIPR is associated with greater morbidity and 30-day mortality. Conversion resulted in outcomes that, at best, mimicked those of open pancreatectomy. Several risk factors including the need for vascular resection are associated with unplanned conversion and should be acknowledged when planning an operative approach.

The Effect of Opioid Use and Mental Illness on Chronic Disease Medication Adherence in Superutilizers

BACKGROUND

Nonadherence to essential chronic medications has been identified as a potential driver of high health care costs in superutilizers of inpatient services. Few studies, however, have documented the levels of nonadherence and factors associated with nonadherence in this high-cost, vulnerable population.

OBJECTIVE

To examine the factors associated with nonadherence to essential chronic medications, with special emphasis on mental illness and use of opioid medications.

METHODS

This study was a retrospective panel analysis of 2-year baseline data for Medicare Part D beneficiaries eligible for the SafeMed care transitions program in Memphis, Tennessee, from February 2013 to December 2014. The 2-year baseline data for each patient were divided into four, 6-month patient periods. The study included Medicare superutilizers (defined as patients with ≥ 3 hospitalizations or ≥ 2 hospitalizations with ≥ 2 emergency visits in 6 months) with continuous Part D coverage who had filled at least 1 drug class used to treat hypertension, diabetes mellitus, congestive heart failure, coronary artery disease, or chronic lung disease. The outcome included medication nonadherence assessed using proportion of days covered (PDC), with PDC < 80% defined as nonadherent, and the main exposure variables included mental illness (defined as a diagnosis of depression or anxiety or ≥ 1 anxiolytic or antidepressant fill) and opioid medication fills assessed in each 6-month period. Pooled observations from the four 6-month periods were used for multivariable analyses using the patient periods as the unit of analysis. A random effects model with robust standard errors and a binary distribution were used to examine associations between independent variables (time invariant and time variant factors) and medication nonadherence. The model included lagged effects of time variant factors measured in each period.

RESULTS

Overall nonadherence to essential chronic medications ranged from 39.3% to 58.4%, with the highest for chronic lung disease medications (49.1%-64.4%). Factors associated with nonadherence included ≥ 4 opioid medication fills in the previous 6-month period (adjusted odds ratio [OR] = 1.90, 95% CI = 1.32-2.73); age 22-44 and 45-64 years vs. ≥ 65 years (OR = 3.57, 95% CI = 2.07-6.16, and OR = 2.07, 95% CI = 1.49-2.88); and a higher number of unique prescribers (OR = 1.10, 95% CI = 1.04-1.17). Factors protecting against nonadherence included higher number of unique medications filled (OR = 0.95, 95% CI = 0.92-0.98) and ≥ 1 physician office visit in the previous 6-month period (OR = 0.66, 95% CI = 0.46-0.94).

CONCLUSIONS

This study demonstrated that high levels of opioid medication use are significantly associated with essential chronic disease medication nonadherence among superutilizers. Other risk factors for nonadherence were aged < 65 years, low-income status, and a higher number of unique prescribers. Factors protecting against nonadherence were physician office visits and filling higher number of medications. Medication management interventions targeting superutilizers should focus on supporting chronic disease medication adherence.

DISCLOSURES

This project was supported by Funding Opportunity Number 1C1CMS331067-01-00 from the Centers for Medicare & Medicaid Services, Center for Medicare and Medicaid Innovation. Support was also provided by the Pharmaceutical Research and Manufacturers of America Foundation. The content of this study is solely the responsibility of the authors. The authors declare no relevant conflicts of interest or financial relationships. Study concept and design were contributed by Surbhi, Bailey, and Graetz. Surbhi and Wan collected the data, and data interpretation was performed primarily by Surbhi, along with Graetz, Bailey, and Gatwood. The manuscript was primarily written by Surbhi, with assistance from Bailey and Graetz, and revised by Bailey, Graetz, Gatwood, and Surbhi. This study was presented as a poster at the Academy Health Annual Research Meeting in Boston, Massachusetts, on June 26-28, 2016.

Racial and Ethnic Disparities in Meeting MTM Eligibility Criteria Based on Star Ratings Compared with the Medicare Modernization Act

BACKGROUND

Previous research found racial and ethnic disparities in meeting medication therapy management (MTM) eligibility criteria implemented by the Centers for Medicare & Medicaid Services (CMS) in accordance with the Medicare Modernization Act (MMA).

OBJECTIVE

To examine whether alternative MTM eligibility criteria based on the CMS Part D star ratings quality evaluation system can reduce racial and ethnic disparities.

METHODS

This study analyzed the Beneficiary Summary File and claims files for Medicare beneficiaries linked to the Area Health Resource File. Three million Medicare beneficiaries with continuous Parts A, B, and D enrollment in 2012-2013 were included. Proposed star ratings criteria included 9 existing medication safety and adherence measures developed mostly by the Pharmacy Quality Alliance. Logistic regression and the Blinder-Oaxaca approach were used to test disparities in meeting MMA and star ratings eligibility criteria across racial and ethnic groups. Multinomial logistic regression was used to examine whether there was a disparity reduction by comparing individuals who were MTM-eligible under MMA but not under star ratings criteria and those who were MTM-eligible under star ratings criteria but not under the MMA. Concerning MMA-based MTM criteria, main and sensitivity analyses were performed to represent the entire range of the MMA eligibility thresholds reported by plans in 2009, 2013, and proposed by CMS in 2015. Regarding star ratings criteria, meeting any 1 of the 9 measures was examined as the main analysis, and various measure combinations were examined as the sensitivity analyses.

RESULTS

In the main analysis, adjusted odds ratios for non-Hispanic blacks (backs) and Hispanics to non-Hispanic whites (whites) were 1.394 (95% CI = 1.375-1.414) and 1.197 (95% CI = 1.176-1.218), respectively, under star ratings. Blacks were 39.4% and Hispanics were 19.7% more likely to be MTM-eligible than whites. Blacks and Hispanics were less likely to be MTM-eligible than whites in some sensitivity analyses. Disparities were not completely explained by differences in patient characteristics based on the Blinder-Oaxaca approach. The multinomial logistic regression of each main analysis found significant adjusted relative risk ratios (RRR) between whites and blacks for 2009 (RRR = 0.459, 95% CI = 0.438-0.481); 2013 (RRR = 0.449, 95% CI = 0.434-0.465); and 2015 (RRR = 0.436, 95% CI = 0.425-0.446) and between whites and Hispanics for 2009 (RRR = 0.559, 95% CI = 0.528-0.593); 2013 (RRR = 0.544, 95% CI = 0.521-0.569); and 2015 (RRR = 0.503, 95% CI = 0.488-0.518). These findings indicate a significant reduction in racial and ethnic disparities when using star ratings eligibility criteria; for example, black-white disparities in the likelihood of meeting MTM eligibility criteria were reduced by 55.1% based on star ratings compared with MMA in 2013. Similar patterns were found in most sensitivity and disease-specific analyses.

CONCLUSIONS

This study found that minorities were more likely than whites to be MTM-eligible under the star ratings criteria. In addition, MTM eligibility criteria based on star ratings would reduce racial and ethnic disparities associated with MMA in the general Medicare population and those with specific chronic conditions.

DISCLOSURES

Research reported in this publication was supported by the National Institute on Aging of the National Institutes of Health under award number R01AG049696. The content of this study is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health. Cushman reports an Eli Lilly grant and uncompensated consulting for Takeda Pharmaceuticals outside this work. The other authors have no potential conflicts of interest to report. Study concept and design were contributed by Wang and Shih, along with Wan, Kuhle, Spivey, and Cushman. Wang, Qiao, and Wan took the lead in data collection, with assistance from the other authors. Data interpretation was performed by Wang, Kuhle, and Qiao, with assistance from the other authors. The manuscript was written by Spivey and Qiao, along with the other authors, and revised by Cushman, Dagogo-Jack, and Chisholm-Burns, along with the other authors.

Parental history of type 2 diabetes is associated with lower resting energy expenditure in normoglycemic subjects

OBJECTIVE

Resting energy expenditure (REE) is linked to obesity, insulin resistance and type 2 diabetes (T2DM). REE and T2DM are inherited traits. Therefore, we investigated the effect of parental T2DM on REE in normoglycemic subjects.

METHODS

Eighty-seven subjects with parental T2DM and 83 subjects without parental T2DM were matched in age, gender, race, BMI, weight and waist circumference. Subjects underwent a 75 g oral glucose tolerance test; REE was determined by indirect calorimetry and body composition was assessed by dual energy X-ray absorptiometry. Statistical analysis was performed using Student's t-test, analysis of variance and regression analysis.

RESULTS

The mean age was 38.8±11.3 years, 57% were females and 53% were African-Americans. The mean BMI was 28.5±6.1 kg/m², waist circumference 91.8±15.1 cm, weight 83.9±20.3 kg, fat mass 31.0%±10.0%, mean fat-free mass (FFM) 54.4±12.9 kg. REE was significantly lower in subjects with parental diabetes, normalized REE 1364.4±263.4Kcal/day vs 1489.4±323.2 Kcal/day, p=0.006 and 29.2±5.3Kcal/kg FFM/day vs 31.9±6.0 Kcal/kg FFM/day, p=0.002. African-Americans had a lower REE compared with Caucasians 28.6±5.4Kcal/kg FFM/day vs 32.6±5.5 Kcal/kg FFM/day, p<0.0001. In a multiple regression model, ethnicity (p<0.0001), parental history of T2DM (p=0.006) and FFM (p=0.021) were independent predictors of REE.

CONCLUSION

Compared with subjects without parental diabetes, offspring with parental T2DM had lower REE, which was more pronounced in African-Americans. This metabolic alteration could increase the risk of obesity, insulin resistance and dysglycemia.

Predictors and implications of unplanned conversion during minimally invasive hepatectomy: an analysis of the ACS-NSQIP database

BACKGROUND

Minimally-invasive hepatectomy (MIH) is increasingly utilized; however, predictors and outcomes for patients requiring conversion to an open procedure have not been adequately studied.

METHODS

The 2014-15 ACS-NSQIP database was analyzed. Unplanned conversion was compared to successful MIH and elective open hepatectomy.

RESULTS

Among 6918 hepatectomies, 1062 (15.4%) underwent attempted MIH: 989 laparoscopic, 73 robotic. Conversion occurred in 203 (19.1%). Compared to successful MIH, patients requiring unplanned conversion experienced higher rates of complications (34.5% vs 14.6%, p<0.001), including bile leaks (7.4% vs 2.8%, p=0.002), organ space infection (6.4% vs 2.9%, p=0.016), UTI (4.9% vs 1.2%, p=0.002), perioperative bleeding (21.2% vs 6.1%, p<0.001), DVT (3.0% vs 0.8%, p=0.024), and sepsis (5.9% vs 1.9%, p=0.001). Conversion led to greater LOS (5 days vs 3 days, p<0.001) and 30-day mortality (3.0% vs 0.5%, p=0.005). Compared to elective open hepatectomy, conversion was associated with greater perioperative bleeding (21.2% vs 15.3%, p = 0.037). On multivariate analysis, major hepatectomy (OR 2.21, p<0.001), concurrent ablation (OR 1.79, p=0.020), and laparoscopic approach (vs. robotic) (OR 3.22, p=0.014) were associated with conversion.

CONCLUSION

Analysis of this national database revealed unplanned conversion during MIH is associated with greater morbidity and mortality. MIH should be approached cautiously in patients requiring major hepatectomy.

Education on Patient-Ventilator Synchrony, Clinicians' Knowledge Level, and Duration of Mechanical Ventilation

BACKGROUND

Improved recognition of patient-ventilator asynchrony may reduce duration of mechanical ventilation.

OBJECTIVE

To evaluate the effects of education about patient-ventilator synchrony on clinicians' level of knowledge and patients' mean duration of mechanical ventilation.

METHODS

A quasi-experimental 1-group pretest-posttest study was performed in a 16-bed intensive care unit. Analysis included 33 clinicians and 97 ventilator patients. The intervention consisted of PowerPoint lectures on patient-ventilator synchrony. Data included test scores before and after the education, scores on the Acute Physiology and Chronic Health Evaluation II, and mean duration of mechanical ventilation. Differences in scores before and after education, mean duration of mechanical ventilation, and mean health evaluation scores before and after education were determined by using t tests.

RESULTS

Of the 33 clinicians, 17 were registered nurses and 16 were respiratory therapists. Posttest scores were 63% higher than pretest scores (P < .001). Before the lecture, 47 patients had a mean health evaluation score of 21 (SD, 7.8) and mean duration of mechanical ventilation of 5.4 (SD, 4.6) days. After the lecture, 50 patients had a mean health evaluation score of 24.6 (SD, 8.2) and mean duration of mechanical ventilation of 4.8 (SD, 4.3) days. Mean health evaluation score was marginally higher after the lecture (P = .054). Mean duration of mechanical ventilation did not differ (P = .54).

CONCLUSIONS

Clinicians' test scores increased significantly after patient-ventilator synchrony lectures. Mean duration of mechanical ventilation decreased by 0.6 days and health evaluation scores were marginally higher after the lectures.

Recruitment methods in a clinical trial of provoked vulvodynia: Predictors of enrollment

BACKGROUND

Successful recruitment in clinical trials for chronic pain conditions is challenging, especially in women with provoked vulvodynia due to reluctance in discussing pain associated with sexual intercourse. The most successful recruitment methods and the characteristics of women reached with these methods are unknown.

OBJECTIVE

To compare the effectiveness and efficiency of four recruitment methods and to determine socioeconomic predictors for successful enrollment in a National Institutes of Health-sponsored multicenter clinical trial evaluating a gabapentin intervention in women with provoked vulvodynia.

METHODS

Recruitment methods utilized mass mailing, media, clinician referrals and community outreach. Effectiveness (number of participants enrolled) and efficiency (proportion screened who enrolled) were determined. Socioeconomic variables including race, educational level, annual household income, relationship status, age, menopausal status and employment status were also evaluated regarding which recruitment strategies were best at targeting specific cohorts.

RESULTS

Of 868 potential study participants, 219 were enrolled. The most effective recruitment method in enrolling participants was mass mailing ( p < 0.001). There were no statistically significant differences in efficiency between recruitment methods ( p = 0.11). Relative to clinician referral, black women were 13 times as likely to be enrolled through mass mailing (adjusted odds ratio 12.5, 95% confidence interval, 3.6-43.1) as white women. There were no differences in enrollment according to educational level, annual income, relationship status, age, menopausal status, or employment status and recruitment method.

CONCLUSION

In this clinical trial, mass mailing was the most effective recruitment method. Race of participants enrolled in a provoked vulvodynia trial was related to the recruitment method.

Venous serum bicarbonate concentration predicts arterial pH in adults with diabetic ketoacidosis

OBJECTIVE

The initial assessment of metabolic acidosis in subjects with diabetic ketoacidosis (DKA) is arterial blood gas analysis. This process is expensive, painful, and technically difficult. Furthermore, blood gas analysis may not be available in some facilities, especially in developing countries where DKA-associated morbidity and mortality remain high. Therefore, we investigated the utility of venous bicarbonate concentration obtained from a basic metabolic panel in predicting arterial pH in adults with DKA.

METHODS

We performed a retrospective analysis of clinical and biochemical data of 396 adults admitted to 2 community teaching hospitals with DKA. We determined the correlation between arterial pH and venous serum parameters. Using multiple logistic regression, we obtained a predictive formula for arterial pH from serum venous bicarbonate level.

RESULTS

The patient population was 59.0% male and had a mean age of 36.7 ± 13.3 years. We derived that arterial pH = 6.97 + (0.0163 x bicarbonate), and by applying this equation, we determined that serum venous bicarbonate concentration of ≤20.6 mEq/L predicted arterial pH ≤7.3 with over 95% sensitivity and 92% accuracy.

CONCLUSION

Venous serum bicarbonate obtained from the basic metabolic panel is an affordable and reliable way of estimating arterial pH in adults with DKA. Validation of this formula in a prospective study would offer a more accessible means of estimating metabolic acidosis in adults with DKA, especially in developing countries where DKA incidence and mortality remain high.

Abstract 4592: MUC13 interaction with receptor tyrosine kinase HER2 drives pancreatic ductal adenocarcinoma progression

Background: Pancreatic Ductal Adenocarcinoma (PDAC) is the fourth leading cause of cancer related death in the United States and has a very poor survival rate due to late diagnosis. MUC13 is a recently identified high molecular weight glycoprotein that is upregulated in PDAC and its progression is allowed via alterations of multiple signaling pathways. MUC13 is aberrantly expressed in PDAC and generally correlates with increased expression of HER2, however, the underlying mechanism remains poorly understood. MUC13 consists of three EGF-like domains that may serve as a ligand for EGF receptors, such as HER2, and modulate EGFR signaling pathways. We sought to better characterize the interaction of MUC13 with HER2 in PDAC.

Methods: MUC13 and HER2 interaction was studied using reciprocal co-immunoprecipitation, immunofluorescence, proximity ligation, Western blotting, co-capping assays in human PDAC cell lines and immunohistofluorescence techniques in human tissues. Tissue microarrays prepared from formalin-fixed, paraffin-embedded specimens of PDAC were assessed for expression of MUC13 and HER2 using our own laboratory generated anti-MUC13 mouse monoclonal antibody (MAb) through confocal immunofluorescence. The association of MUC13 and HER2 co-localization with nuclear chromatin organization was analyzed to study the stage or degree of aggressiveness of the pancreatic cancer using Dapi stained confocal images of tissues.

Results: MUC13 co-localizes and interacts with HER2 in PDAC cell lines. The results from this study demonstrate that MUC13 functionally interacts and activates HER2 at Tyrp1248 in PDAC cells, leading to stimulation of HER2 signaling cascade including, ERK1/2, FAK, AKT and PAK1 as well as regulation of the growth, cytoskeleton remodeling, motility and invasion of PDAC cells - all collectively contributing to PDAC progression. The interaction between MUC13-HER2 binding resulting in their tumorigenic characteristics likely occurs at the 1st and 2nd but not the 3rd domains of MUC13 as the EGF 1 and 2 deletion mutant constructs of MUC13 failed to promote proliferation and invasion of cells. These phenotypic effects of MUC13-HER2 co-localization could be effectively compromised by depleting MUC13. MUC13-HER2 co-localization also held true in PDAC human tissues with a strong functional correlation that contributed to an increased degree of disorder and cancer aggressiveness.

Conclusions: 1) MUC13 can be detected in formalin-fixed paraffin-embedded tissues using our anti-MUC13 MAb. 2) MUC13 co-localizes and activates HER2 and its downstream signaling cascade promoting PDAC progression in both cell lines and human tissue. 3) This process is reversed by depletion of MUC13. 4) This MUC13-HER2 interaction may potentially be manipulated for targeted therapeutics in patients harboring PDAC.

Citation Format: Sheema Khan, Mara C. Ebeling, Mohammad Sikander, Murali M. Yallapu, Tomoko Ise, Satoshi Nagata, Stephen W. Behrman, Nadeem Zafar, Jim Y. Wan, Hemendra M. Ghimire, Peeyush Sahay, Prabhakar Pradhan, Meena Jaggi, Subhash C. Chauhan. MUC13 interaction with receptor tyrosine kinase HER2 drives pancreatic ductal adenocarcinoma progression. [abstract]. In: Proceedings of the 107th Annual Meeting of the American Association for Cancer Research; 2016 Apr 16-20; New Orleans, LA. Philadelphia (PA): AACR; Cancer Res 2016;76(14 Suppl):Abstract nr 4592.

Measuring Health-Related Quality of Life of Adults With Down Syndrome

This study examined self- and caregiver-reported health-related quality of life (HRQOL) of 60 adults with Down syndrome (DS) using the QualityMetric Short Form-12 version 2 (SF-12v2). All HRQOL scores exceeded means and fell within one standard deviation of the SF-12v2 normative sample. Similarities between eight self- and caregiver-reported HRQOL scales were found with the exception of role physical scores (impact of health problems on typical accomplishments), which were lower when obtained by caregiver-report. A positive association was found between self- and caregiver-reported physical functioning scores (impact of health problems on physical activity). The SF-12v2 had high construct validity in this study. These findings support the feasibility of measuring HRQOL of adults with DS using self-report rather than reliance on caregiver-report.

Potential Health Implications of Medication Therapy Management Eligibility Criteria in the Patient Protection and Affordable Care Act Across Racial and Ethnic Groups

BACKGROUND

The Medicare Prescription Drug, Improvement, and Modernization Act requires Part D plans to establish programs to provide medication therapy management (MTM) services starting from 2006. MTM services have been found to improve patient outcomes from pharmacotherapy, reduce emergency room visits and hospitalizations, and reduce health care costs in a cost-effective fashion. However, previous research found that non-Hispanic blacks (blacks) and Hispanics may be less likely to be eligible for MTM services than non-Hispanic whites (whites) among the Medicare population, according to current Medicare MTM eligibility criteria. This finding is because Medicare MTM eligibility criteria are predominantly based on medication use and costs, and blacks and Hispanics tend to use fewer prescription medications and incur lower prescription medication costs. The Patient Protection and Affordable Care Act (PPACA) laid out a set of MTM eligibility criteria for eligible entities to target patients for MTM services: "(1) take 4 or more prescribed medications ...; (2) take any 'high risk' medications; (3) have 2 or more chronic diseases ... or (4) have undergone a transition of care, or other factors ... that are likely to create a high risk of medication-related problems."

OBJECTIVES

To (a) examine racial/ethnic disparities in meeting the eligibility criteria for MTM services in PPACA among the Medicare population and (b) determine whether there would be greater disparities in health and economic outcomes among MTM-ineligible than MTM-eligible groups.

METHODS

This was a retrospective cross-sectional analysis of the Medicare Current Beneficiaries Survey (2007-2008). To determine medication characteristics, the U.S. Food and Drug Administration's Electronic Orange Book was also used. Proportions of the population eligible for MTM services based on PPACA MTM eligibility criteria were compared across racial and ethnic groups using a chi-square test; a logistic regression model was used to adjust for population sociodemographic and health characteristics. Health and economic outcomes examined included health status (self-perceived good health status, number of chronic diseases, activities of daily living [ADLs], and instrumental activities of daily living [IADLs]), health services utilization and costs (physician visits, emergency room visits, and total health care costs), and medication use patterns (generic dispensing ratio). To determine difference in disparities across MTM eligibility categories, difference-in-differences regressions of various functional forms were employed, depending on the nature of the dependent variables. Interaction terms between the dummy variables for minority groups (e.g., blacks or Hispanics) and MTM eligibility were included to test whether disparity patterns varied between MTM-ineligible and MTM-eligible individuals.

RESULTS

The sample consisted of 12,966 Medicare beneficiaries, of which 11,161 were white, 930 were black, and 875 were Hispanic. Of the study sample, 9,992 whites (86.4%), 825 blacks (86.3%), and 733 Hispanics (80.6%) were eligible for MTM. The difference between whites and Hispanics was significant (P  less than  0.050), and the difference between whites and blacks was not significant (P  greater than 0.050). In multivariate analyses, significant disparity in eligibility for MTM services was found only between Hispanics and whites (odds ratio [OR] = 0.59; 95% CI = 0.43-0.82) but not between blacks and whites (OR = 0.78; 95% CI = 0.55-1.09). Disparities were greater among the MTM-ineligible than the MTM-eligible populations in self-perceived health status, ADLs, and IADLs for both blacks and Hispanics compared with whites. When analyzing the number of chronic conditions, the number and costs of physician visits, and total health care costs, the authors of this study found lower racial and ethnic disparities among the ineligible population than the eligible population.

CONCLUSIONS

Hispanics are significantly less likely than whites to qualify for MTM among the Medicare population, according to MTM eligibility criteria stipulated in the PPACA. PPACA MTM eligibility criteria may aggravate existing racial and ethnic disparities in health status but may remediate racial and ethnic disparities in health services utilization. Alternative MTM eligibility criteria other than PPACA MTM eligibility criteria may be needed to improve the efficiency and equity of access to Medicare Part D MTM programs.

Presenting Symptoms Among Black and White Women with Provoked Vulvodynia

BACKGROUND

The prevalence of vulvodynia has been reported to be lower in black compared to white and Latina women. Use of different terminology to describe vulvar pain symptoms may play a role in lower prevalence. The objectives were to compare pain descriptors used by black and white women with provoked vulvodynia (PVD) to determine the effect of race on symptom reporting.

METHODS

Ninety-two women, self-identified as black (n = 55) and white (n = 37) with clinically confirmed PVD completed a questionnaire containing demographic information and vulvar pain characteristics. Variables that were significant with race retained in the logistic regression model were included in multivariate analysis to determine the effect of race on reporting of vulvar pain symptoms.

RESULTS

Of statistical significance, white women more often described their pain as burning as compared with black women (84% vs. 22%, p ≤ 0.0001). White women more frequently reported their pain as stinging (51% vs. 29%, p = 0.03) and itching (32% vs. 15%, p = 0.04) as well, whereas there was a trend for black women to more often describe their pain as aching (67% vs. 49%, p = 0.07). Overall, white women were 19 times as likely to report their pain as burning (adjusted odds ratio [aOR] 18.51, 99% confidence interval [CI] 4.46-76.86).

CONCLUSIONS

These data suggest that black women are less likely to self-report their vulvar pain as burning, the classic symptom of PVD. Cultural influences and different underlying pain mechanisms may contribute to differences in symptom reporting by race.

Cigarette smoking increases complication rate in forefoot surgery

BACKGROUND

Cigarette smoking is known to increase perioperative complication rates, but no study to date has examined its effect specifically in forefoot surgery. The purpose of this study was to determine whether cigarette smoking increased complications after forefoot surgery.

METHODS

The records of 602 patients who had forefoot surgery between 2008 and 2010, and for whom smoking status was known, were reviewed. Patients were categorized into 3 groups based on smoking status: active smoker, smoker in the past, or nonsmoker. Medical records were reviewed for occurrence of complications, including nonunion, delayed union, delayed wound healing, infection, and persistent pain.

RESULTS

Active smokers were found to have a notably higher complication rate (36.4%) after forefoot surgery than patients who previously (16.5%) or never (8.5%) smoked. Patients who continued to smoke in the perioperative period had the highest percentage of delayed union (3.0%), infection (9.1%), delayed wound healing (10.6%), and persistent pain (15.2%). Active cigarette smokers were 4.3 times more likely to have a complication than nonsmokers. Patients who smoked at any point in the past but quit prior to surgery were 1.9 times more likely than nonsmokers to incur a complication. The average time of smoking cessation for patients who had smoked at any point in the past but had quit prior to surgery was 17 years. For active smokers, those with a complication smoked an average of 18 cigarettes daily, while those without a complication smoked 14 cigarettes daily.

CONCLUSIONS

Before forefoot surgery, surgeons should educate patients who smoke about their increased risk of complications and encourage smoking cessation.

LEVEL OF EVIDENCE

Level III, retrospective comparative study.

Differential loss of thalamostriatal and corticostriatal input to striatal projection neuron types prior to overt motor symptoms in the Q140 knock-in mouse model of Huntington's disease

Motor slowing and forebrain white matter loss have been reported in premanifest Huntington's disease (HD) prior to substantial striatal neuron loss. These findings raise the possibility that early motor defects in HD may be related to loss of excitatory input to striatum. In a prior study, we showed that in the heterozygous Q140 knock-in mouse model of HD that loss of thalamostriatal axospinous terminals is evident by 4 months, and loss of corticostriatal axospinous terminals is evident at 12 months, before striatal projection neuron pathology. In the present study, we specifically characterized the loss of thalamostriatal and corticostriatal terminals on direct (dSPN) and indirect (iSPN) pathway striatal projection neurons, using immunolabeling to identify thalamostriatal (VGLUT2+) and corticostriatal (VGLUT1+) axospinous terminals, and D1 receptor immunolabeling to distinguish dSPN (D1+) and iSPN (D1-) synaptic targets. We found that the loss of corticostriatal terminals at 12 months of age was preferential for D1+ spines, and especially involved smaller terminals, presumptively of the intratelencephalically projecting (IT) type. By contrast, indirect pathway D1- spines showed little loss of axospinous terminals at the same age. Thalamostriatal terminal loss was comparable for D1+ and D1- spines at both 4 and 12 months. Regression analysis showed that the loss of VGLUT1+ terminals on D1+ spines was correlated with a slight decline in open field motor parameters at 12 months. Our overall results raise the possibility that differential thalamic and cortical input loss to SPNs is an early event in human HD, with cortical loss to dSPNs in particular contributing to premanifest motor slowing.

Multimodal pain control is associated with reduced hospital stay following open abdominal hysterectomy

OBJECTIVE

To study the association of a multimodal pain protocol (MMPC) and reduced hospital stay after open abdominal hysterectomy.

STUDY DESIGN

The study design was a comparison of a prospective cohort with a retrospective historical control. We enrolled endometrial cancer patients undergoing open abdominal hysterectomy with lymphadenectomy by the same surgeon. Control patients from 2008 to 2010 who received morphine PCA alone were compared with a similar demographic group of patients from 2011 to 2013 who received MMPC. MMPC consisted of gabapentin (900mg PO) and acetaminophen (1g IV) administered 45-60min preoperatively. The surgical site was injected with bupivacaine with 0.5% epinephrine prior to incision. The postoperative pain control regimen consisted of gabapentin (300mg PO every 6h), acetaminophen (1g IV every 8h for 24h postoperatively), ketorolac (15mg IV every 6h for 48h postoperatively), morphine PCA (2mg IV every 10min, no basal rate) and oxycodone/acetaminophen (10/325mg PO every 6h as needed).

RESULTS

Length of hospital stay (LOH) of the study cohort (N=105 with MMPC) was compared with the historical with postoperative morphine alone (N=113 without MMPC). There were no differences in demographic, uterine cancer stage, or comorbidities between the two arms. The LOH was 1.6 days for patients receiving MMPC and 3.3 days for patients who received morphine alone (P<0.001).

CONCLUSION

Multimodal pain control is associated with significantly reduced hospital stay after open abdominal hysterectomy.

Effects of medicare part d on disparity implications of medication therapy management eligibility criteria

BACKGROUND

Previous studies have shown that there were greater racial and ethnic disparities among individuals who were ineligible for medication therapy management (MTM) services than among MTM-eligible individuals before the implementation of Medicare Part D in 2006.

OBJECTIVE

To determine whether the implementation of Medicare Part D in 2006 correlates to changes in racial and ethnic disparities among MTM-ineligible and MTM-eligible beneficiaries.

METHODS

Data from the Medicare Current Beneficiary Survey were analyzed in this retrospective observational analysis. To examine potential racial and ethnic disparities, non-Hispanic whites were compared with non-Hispanic blacks and Hispanics. Three aspects of disparities were analyzed, including health status, health services utilization and costs, and medication utilization patterns. A generalized difference-in-differences analysis was used to examine the changes in difference in disparities between MTM-ineligible and MTM-eligible individuals from 2004-2005 to 2007-2008 relative to changes from 2001-2002 and 2004-2005. Various multivariate regressions were used based on the types of dependent variables. A main analysis and several sensitivity analyses were conducted to represent the ranges of MTM eligibility thresholds used by Medicare Part D plans in 2010.

RESULTS

The main analysis showed that Part D implementation was not associated with reductions in greater racial and ethnic disparities among MTM-ineligible than MTM-eligible Medicare beneficiaries. The main analysis suggests that after Part D implementation, Medicare MTM eligibility criteria may not consistently improve the existing racial and ethnic disparities in health status, health services utilization and costs, and medication utilization. By contrast, several sensitivity analyses showed that Part D implementation did correlate with a significant reduction in greater racial disparities among the MTM-ineligible group than the MTM-eligible group in activities of daily living and in instrumental activities of daily living. Part D implementation may be also associated with a reduction in greater ethnic disparities among the MTM-ineligible group than the MTM-eligible groups in the costs of physician visits.

CONCLUSION

Part D implementation was not associated with consistent reductions in the disparity implications of the Medicare MTM eligibility criteria. The main analysis showed that Part D implementation was not associated with a reduction in disparities associated with MTM eligibility, although several sensitivity analyses did show reductions in disparities in specific aspects. Future research should explore alternative Medicare MTM eligibility criteria to eliminate racial and ethnic disparities among the Medicare population.

Potential effects of racial and ethnic disparities in meeting Medicare medication therapy management eligibility criteria

OBJECTIVE

Medication therapy management (MTM) has the potential to play an instrumental role in reducing racial and ethnic disparities in health care. However, previous research has found that Blacks and Hispanics are less likely to be eligible for MTM. The purpose of the current study was to examine the potential effects of MTM eligibility criteria on racial and ethnic disparities in health outcomes.

METHODS

The current study is a retrospective cross-sectional analysis of the Medicare Current Beneficiary Survey Cost and Use files for the years 2007 and 2008. A difference-in-differences model was used to compare disparities in outcomes between ineligible and eligible beneficiaries according to MTM eligibility criteria in 2010. This was achieved by including in regression models interaction terms between dummy variables for Blacks/Hispanics and MTM eligibility criteria. Interaction terms were interpreted on both multiplicative and additive terms. Various regression models were used depending on the types of variables.

KEY FINDINGS

Whites were more likely to report self-perceived good health status than Blacks and Hispanics among both MTM-eligible and MTM-ineligible populations. Disparities were greater among MTM-ineligible than MTM-eligible populations (e.g., on additive term, difference in odds=1.94 and P<0.01 for Whites and Blacks; difference in odds=2.86 and P<0.01 for Whites and Hispanics). A few other measures also exhibited significant patterns.

CONCLUSIONS

MTM eligibility criteria may exacerbate racial and ethnic disparities in health status and some measures of health services utilizations and costs and medication utilization. Future research should examine strategies to remediate the effects of MTM eligibility criteria on disparities.

Impact of renal surgery for cortical neoplasms on lipid metabolism

OBJECTIVE

To examine the incidence of and risk factors for development of hyperlipidaemia in patients undergoing radical nephrectomy (RN) or partial nephrectomy (PN) for renal cortical neoplasms, as hyperlipidaemia is a major source of morbidity in chronic kidney disease (CKD).

PATIENTS AND METHODS

We conducted a two-centre retrospective analysis of 905 patients (mean age 57.5 years, mean follow-up 78 months), who underwent RN (n = 610) or PN (n = 295) between July 1987 and June 2007. Demographics, preoperative and postoperative hyperlipidaemia were recorded. De novo hyperlipidaemia was defined as that ocurring ≥6 months after surgery in cases where laboratory values met National Cholesterol Education Program Adult Treatment Panel III definitions. The Kaplan-Meier method was used to assess freedom from de novo hyperlipidaemia. Multivariable analysis was conducted to determine the risk factors for de novo hyperlipidaemia.

RESULTS

There were no significant differences with respect to demographics, preoperative glomerular filtration rate (GFR) <60 mL/min/1.73 m(2) (P = 0.123) and hyperlipidaemia (P = 0.144). Tumour size (cm) was significantly larger in the RN group vs the PN group (7.0 vs 3.7; P < 0.001). Significantly greater postoperative GFR <60 mL/min/1.73 m(2) was noted in the RN group (45.7 vs 18%, P < 0.001). Significantly, more de novo hyperlipidaemia developed in the RN group than in the PN group (23 vs 6.4%; P < 0.001). The mean time to development of hyperlipidaemia was longer for PN than for RN (54 vs 44 months; P = 0.03). Five-year freedom from de novo hyperlipidaemia probability was 76% for RN vs 96% for PN (P < 0.001). Multivariable analysis showed that RN (odds ratio [OR] 2.93; P = 0.0107), preoperative GFR <60 mL/min/1.73 m(2) (OR 1.98; P = 0.037) and postoperative GFR <60 mL/min/1.73 m(2) (OR 7.89; P < 0.001) were factors associated with hyperlipidaemia development.

CONCLUSION

Patients who underwent RN had a significantly higher incidence of and shorter time to development of de novo hyperlipidaemia. RN and pre- and postoperative eGFR <60 mL/min/1.73 m(2) were associated with development of hyperlipidaemia. Further follow-up and prospective investigation are necessary to confirm these findings.