Social Determinants Matter For Hospital Readmission Policy: Insights From New York City

This study assessed the impact of individual social risk factor variables and social determinants of health (SDOH) measures on hospital readmission rates and penalties used in the Centers for Medicare and Medicaid Services (CMS) Hospital Readmissions Reduction Program (HRRP). Using 2012-16 hospital discharge data from New York City, we projected HRRP penalties by augmenting CMS's readmission model for heart attack, heart failure, and pneumonia with SDOH scores constructed at each of four geographic levels and a measure of individual-level social risk. Including additional SDOH scores in the model, especially those constructed with the most granular geographic data, along with social risk factor variables substantially affects projected penalties for hospitals treating the highest proportion of patients with high SDOH scores. Improved performance occurred even after we included peer-group stratification in the HRRP model pursuant to the 21st Century Cures Act. Small improvements in model accuracy were associated with substantial shifts in projected performance. Our results suggest that CMS's continued omission of relevant patient and geographic data from the HRRP readmission model misallocates penalties attributable to SDOH and social risk factor effects to hospitals with the largest share of high-risk patients.

Interaction between host genes and Mycobacterium tuberculosis lineage can affect tuberculosis severity: Evidence for coevolution?

Genetic studies of both the human host and Mycobacterium tuberculosis (MTB) demonstrate independent association with tuberculosis (TB) risk. However, neither explains a large portion of disease risk or severity. Based on studies in other infectious diseases and animal models of TB, we hypothesized that the genomes of the two interact to modulate risk of developing active TB or increasing the severity of disease, when present. We examined this hypothesis in our TB household contact study in Kampala, Uganda, in which there were 3 MTB lineages of which L4-Ugandan (L4.6) is the most recent. TB severity, measured using the Bandim TBscore, was modeled as a function of host SNP genotype, MTB lineage, and their interaction, within two independent cohorts of TB cases, N = 113 and 121. No association was found between lineage and severity, but association between multiple polymorphisms in IL12B and TBscore was replicated in two independent cohorts (most significant rs3212227, combined p = 0.0006), supporting previous associations of IL12B with TB susceptibility. We also observed significant interaction between a single nucleotide polymorphism (SNP) in SLC11A1 and the L4-Ugandan lineage in both cohorts (rs17235409, meta p = 0.0002). Interestingly, the presence of the L4-Uganda lineage in the presence of the ancestral human allele associated with more severe disease. These findings demonstrate that IL12B is associated with severity of TB in addition to susceptibility, and that the association between TB severity and human genetics can be due to an interaction between genes in the two species, consistent with host-pathogen coevolution in TB.

Cost savings associated with video directly observed therapy for treatment of tuberculosis

OBJECTIVE: To calculate the per-session and annual direct program costs to implement directly observed therapy (DOT) for tuberculosis treatment and to conduct a cost attribution analysis under varying proportions of DOT utilization for four DOT types.DESIGN: Program data covering the study period from September 2014 to August 2015 in New York City (NYC) were used to conduct a retrospective bottom-up micro-costing economic evaluation. For each DOT type, potential per-session and annual program savings were estimated as the cost averted by adopting a uniform distribution of DOT alternatives. Sensitivity analyses explored aggregate cost impacts of unequal distributions.RESULTS: There was a total of 38 035 unique DOT visits, of which 12 002 (32%) were clinic-based (CDOT); 15 483 (41%) were field-based (FDOT); 7185 (19%) were live-video (LVDOT); and 3365 (9%) were recorded-video (RVDOT). The per-session direct costs (in 2016 $US) for DOT services delivered during the study period were $8.46 for CDOT; $19.83 for FDOT; $6.54 for LVDOT; and $5.35 for RVDOT. Sensitivity analyses supported the main findings.CONCLUSIONS: Significant cost savings were estimated with increased utilization of VDOT. Assuming equivalent treatment adherence, duration, completion, and adverse events across DOT types, RVDOT was the modality that most minimized cost.

Evaluating reimbursement of integrated support services using chronic care management (CCM) codes for treatment of hepatitis C among Medicare beneficiaries

The New York City Department of Health and Mental Hygiene (DOHMH) implemented Project INSPIRE, an integrated model of hepatitis C care coordination and telementoring services, from 2014 to 2017. We evaluated the use of chronic care management (CCM) codes to sustain the intervention. DOHMH data were collected as part of a Healthcare Innovation Award from the Centers for Medicare & Medicaid Services (CMS). A retrospective cohort medical billing study was conducted by assigning INSPIRE activities to procedure codes in both facility and nonfacility settings. Rates for procedures were extracted from the CMS's 2018 fee schedules and added across the eligibility periods for Medicare enrollees. Reimbursement was adjusted on the basis of expected patient attrition and compared to costs. The minimum number needed to treat (NNT) to break even was calculated in each setting. Facility reimbursement was higher than costs, whereas nonfacility reimbursement was lower (both P < .01). The NNT was 23 patients in facilities and 33 patients in nonfacilities; 24 patients per care coordinator were treated annually in INSPIRE. CCM fees alone were insufficient to fully reimburse the costs in either setting. Implementation of an appropriate risk financing strategy is necessary to mitigate financial shortfalls when providing CCM services in facility settings.

Impact of geographic distance on appraisal delay for active TB treatment seeking in Uganda: a network analysis of the Kawempe Community Health Cohort Study

Background

Appraisal delay is the time a patient takes to consider a symptom as not only noticeable, but a sign of illness. The study’s objective was to determine the association between appraisal delay in seeking tuberculosis (TB) treatment and geographic distance measured by network travel (driving and pedestrian) time (in minutes) and distance (Euclidean and self-reported) (in kilometers) and to identify other risk factors from selected covariates and how they modify the core association between delay and distance.

Methods

This was part of a longitudinal cohort study known as the Kawempe Community Health Study based in Kampala, Uganda. The study enrolled households from April 2002 to July 2012. Multivariable interval regression with multiplicative heteroscedasticity was used to assess the impact of time and distance on delay. The delay interval outcome was defined using a comprehensive set of 28 possible self-reported symptoms. The main independent variables were network travel time (in minutes) and Euclidean distance (in kilometers). Other covariates were organized according to the Andersen utilization conceptual framework.

Results

A total of 838 patients with both distance and delay data were included in the network analysis. Bivariate analyses did not reveal a significant association of any distance metric with the delay outcome. However, adjusting for patient characteristics and cavitary disease status, the multivariable model indicated that each minute of driving time to the clinic significantly (p = 0.02) and positively predicted 0.25 days’ delay. At the median distance value of 47 min, this represented an additional delay of about 12 (95% CI: [3, 21]) days to the mean of 40 days (95% CI: [25, 56]). Increasing Euclidean distance significantly predicted (p = 0.02) reduced variance in the delay outcome, thereby increasing precision of the mean delay estimate. At the median Euclidean distance of 2.8 km, the variance in the delay was reduced by more than 25%.

Conclusion

Of the four geographic distance measures, network travel driving time was a better and more robust predictor of mean delay in this setting. Including network travel driving time with other risk factors may be important in identifying populations especially vulnerable to delay.

Electronic supplementary material

The online version of this article (10.1186/s12889-018-5648-6) contains supplementary material, which is available to authorized users.

Environmental factors influencing the link between childhood ADHD and risk of adult coronary artery disease

Yorbik et al. reported novel findings regarding a hypothesized relationship between childhood attention-deficit hyperactivity disorder (ADHD) and later risk for coronary heart disease in adulthood. The authors found that mean platelet volume (MPV), a marker of platelet reactivity and a presumable biomarker in patients with cardiovascular disease, was significantly elevated in children with ADHD compared to healthy controls. The mechanistic importance of this novel discovery remains unknown and warrants clarification. We have made the novel proposition that environmental exposure to the agricultural and combustion air pollutant, nitrous oxide (N₂O), may be an etiological contributor to neurodevelopmental disorders. Clinical studies suggest that N₂O may enhance platelet hyperaggregation, possibly via its biphasic role as an MAO inhibitor especially at trace levels of exposure or via the generation of oxidative stress. Therefore, this correspondence briefly details the hypothesis that altered biochemical profiles in neurodevelopmental disorders, derived from chronic environmental exposure to the agricultural and combustion air pollutant, N₂O, may promote coronary artery disease in adulthood.

Use of anthropogenic nitrogen fertilizers in agriculture is associated with per capita ethanol consumption

It has previously been demonstrated that emissions of the agricultural pollutant, nitrous oxide (N₂O), may be a confounder to the relationship between herbicide use and psychiatric impairments, including ADHD. This report attempts to extend this hypothesis by testing whether annual use of anthropogenic nitrogen-based fertilizers in U.S. agriculture (thought to be the most reliable indicator of environmental N₂O emissions) is associated with per capita ethanol consumption patterns, a behavior often comorbid with ADHD. State estimates of anthropogenic nitrogen fertilizers from the United States Geological Survey (USGS) were obtained for the years between 1987 and 2006. Our dependent variable was annual per capita ethanol consumption. Ethanol consumption was categorized as beer, wine, spirits, and all alcoholic beverages. Least squares dummy variable method using two-ways fixed effects was utilized. Among states above the 50th percentile in farm use of anthropogenic nitrogen for all years (i.e., agricultural states), a one log-unit increase in farm use of anthropogenic nitrogen fertilizers is associated with a 0.13 gallon increase in total per capita ethanol consumption (p<0.0125). No statistically significant association between farm use of anthropogenic nitrogen and per capita ethanol consumption was found in states below the 50th percentile in farm use of anthropogenic nitrogen. The new findings are in agreement with both behavioral human studies demonstrating a link between N₂O preference and alcohol and drug use history as well as molecular studies elucidating shared mechanisms between trace N₂O antinociception and alcohol-seeking related behaviors.

Air pollution and risk of hospitalization for epilepsy: the role of farm use of nitrogen fertilizers and emissions of the agricultural air pollutant, nitrous oxide

ABSTRACT The link between various air pollutants and hospitalization for epilepsy has come under scrutiny. We have proposed that exposure to air pollution and specifically the pervasive agricultural air pollutant and greenhouse gas, nitrous oxide (N2O), may provoke susceptibility to neurodevelopmental disorders. Evidence supports a role of N2O exposure in reducing epileptiform seizure activity, while withdrawal from the drug has been shown to induce seizure-like activity. Therefore, we show here that the statewide use of anthropogenic nitrogen fertilizers (the most recognized causal contributor to environmental N2O burden) is significantly negatively associated with hospitalization for epilepsy in all three pre-specified hospitalization categories, even after multiple pollutant comparison correction (p<.007), while the other identified pollutants were not consistently statistically significantly associated with hospitalization for epilepsy. We discuss potential neurological mechanisms underpinning this association between air pollutants associated with farm use of anthropogenic nitrogen fertilizers and hospitalization for epilepsy.

Anesthetic agents, neurodevelopmental risk and the connection to bacterial infections

This short communication identifies a significant flaw in research investigating the neurodevelopmental consequences of general anesthesia exposure. We have identified that chronic environmental exposure to pervasive air pollutants that are also widely used as anesthetic agents, specifically nitrous oxide (N₂O), may contribute to the rising prevalence of neurodevelopmental disorders. Consistent with the emerging link between microbes and psychiatric illness risk, this epidemiological analysis extends our prior conclusions by proposing that such exposures may alter host immunity so as to enhance vulnerability to certain pathogenic microbes that have been implicated in neurodevelopmental disorders, including Pseudomonas aeruginosa and Clostridium difficile.

Exposure to ambient PM10 and nitrogen dioxide and ADHD risk: A reply to Min & Min (2017)

Min and Min (2017) conducted an epidemiological investigation that revealed further support of a link between exposure to air pollution and risk for attention-deficit hyperactivity disorder (ADHD) in childhood. We have previously reported that exposure to the agricultural and combustion pollutant, nitrous oxide (N₂O), may be a primary environmental trigger in the onset of neurodevelopmental disorders, like ADHD and autism spectrum disorders. In order to validate our prior work pointing to an association between farm use of nitrogen fertilizers and a severe ADHD phenotype, we have utilized a different statistical approach (i.e., Poisson regression methodology) including two-way fixed effects. The results reported in this correspondence indicate that for a one-log unit increase in the farm use of nitrogen fertilizers, hospitalization risk for ADHD and conduct disorders increases by a factor of 1.16 (p<0.017), which was a statistically significant increase in risk after multiple pollutant comparison correction. Exposure to PM10 and NOx in this analysis was not associated with an increased risk of hospitalization for ADHD and conduct disorder. We are able to validate our prior conclusions and, therefore, suggest that future analyses dedicated to improving the literature on the association between air pollution and risk of ADHD take into account environmental emissions of N₂O.

The new frontier in health services research: a behavioural paradigm guided by genetics

The incorporation of genetics into health services research has largely floundered, despite the rapidly accelerating availability of, and access to, such data. This is expected given the ethical questions involved. However, using these new resources robustly to examine population choices when it comes to health insurer selection, coverage therein and especially the subsequent use of health services is a necessary step forward, especially given the increasing prevalence of multimorbidity. Such a novel advancement in health services research may eventually propel public and private insurers to redesign their infrastructure to more accurately reflect the behavioural inclinations of their beneficiary populations. Using this resource will likely provide equally important insight for countries with extensive mixed insurer systems (like the United States) or nations with a greater emphasis on single-payer systems (such as various European models).

Community water fluoridation predicts increase in age-adjusted incidence and prevalence of diabetes in 22 states from 2005 and 2010

Community water fluoridation is considered a significant public health achievement of the 20th century. In this paper, the hypothesis that added water fluoridation has contributed to diabetes incidence and prevalence in the United States was investigated. Panel data from publicly available sources were used with population-averaged models to test the associations of added and natural fluoride on the outcomes at the county level in 22 states for the years 2005 and 2010. The findings suggest that a 1 mg increase in the county mean added fluoride significantly positively predicts a 0.23 per 1,000 person increase in age-adjusted diabetes incidence (P < 0.001), and a 0.17% increase in age-adjusted diabetes prevalence percent (P < 0.001), while natural fluoride concentration is significantly protective. For counties using fluorosilicic acid as the chemical additive, both outcomes were lower: by 0.45 per 1,000 persons (P < 0.001) and 0.33% (P < 0.001), respectively. These findings are adjusted for county-level and time-varying changes in per capita tap water consumption, poverty, year, population density, age-adjusted obesity and physical inactivity, and mean number of years since water fluoridation started. Sensitivity analyses revealed robust effects for both types of fluoride. Community water fluoridation is associated with epidemiological outcomes for diabetes.

Identification and immunoreactivity of proteins released from Streptococcus agalactiae

The aim of the present study was to identify released proteins of Streptococcus agalactiae and to investigate their immunoreactivity with human sera to determine whether such proteins might be viable as carrier proteins in conjugate vaccines. Infections with S. agalactiae are the leading cause of sepsis and meningitis in neonates. Vaccination of women of childbearing age would be a desirable alternative to intrapartum antibiotic prophylaxis, but factors that mediate S. agalactiae invasive disease and virulence are poorly defined. Capsule-based vaccines have shown only low immunogenicity to date, and interest has shifted towards S. agalactiae proteins, either as candidate vaccine antigens or as carrier proteins for serotype-specific S. agalactiae polysaccharides. In this study, some major released proteins of S. agalactiae could be identified, including molecules known to be present on the surface of bacterial cells but not previously described as released proteins, such as CAMP factor, a phosphocarrier protein, aldolase, enolase, PcsB, and heat-shock protein 70. Serotype-specific differences in the protein patterns of extracellular products and immunoreactivity with human sera could be detected by SDS-PAGE and Western blot. The identification of unexpected released proteins may indicate secondary functions for these proteins. In addition, the widespread immunoreactivity of these proteins with human sera as shown by Western blot indicates that released proteins may be promising candidates as carrier proteins in conjugate vaccines.

Late onset group B streptococcal disease manifested by isolated cervical lymphadenitis

Sepsis and meningitis are the major clinical manifestations of group B streptococcal (GBS) infections in neonates, but GBS can cause a wide spectrum of presentations ranging from asymtomatic bacteraemia to fulminate septicaemia and shock. To our knowledge this is the first report of isolated neonatal lymphadenitis as a manifestation of late onset GBS disease.