Deriving life-course residential histories in brain bank cohorts: A feasibility study

INTRODUCTION

The exposome is theorized to interact with biological mechanisms to influence risk for Alzheimer's disease but is not well-integrated into existing Alzheimer's Disease Research Center (ADRC) brain bank data collection.

METHODS

We apply public data tracing, an iterative, dual abstraction and validation process rooted in rigorous historic archival methods, to develop life-course residential histories for 1254 ADRC decedents.

RESULTS

The median percentage of the life course with an address is 78.1% (IQR 24.9); 56.5% of the sample has an address for at least 75% of their life course. Archivists had 89.7% agreement at the address level. This method matched current residential survey methodology 97.4% on average.

DISCUSSION

This novel method demonstrates feasibility, reproducibility, and rigor for historic data collection. To our knowledge, this is the first study to show that public data tracing methods for brain bank decedent residential history development can be used to better integrate the social exposome with biobank specimens.

HIGHLIGHTS

Public data tracing compares favorably to survey-based residential history. Public data tracing is feasible and reproducible between archivists. Archivists achieved 89.7% agreement at the address level. This method identifies residences for nearly 80% of life-years, on average. This novel method enables brain banks to add social characterizations.

Alzheimer's Incidence and Prevalence with and without Asthma: A Medicare cohort study

BACKGROUND

International data suggest that asthma, like other inflammatory diseases, might increase Alzheimer's disease (AD) risk.

OBJECTIVE

To explore risk pathways and future mitigation strategies by comparing diagnostic claims-based AD incidence and prevalence among US patients with asthma to non-asthma patients.

METHODS

This cohort study included a national Medicare 20% random sample 2013-2015. Adult patients with >12 months continuous Medicare with asthma were compared to non-asthma subjects overall and as matched. Asthma was defined by one inpatient or two outpatient codes for asthma. The main outcomes were two-year incident or prevalent AD defined as any codes for ICD-9 331.0 or ICD-10 G30.0, G30.1, G30.8, G30.9.

RESULTS

Among 5,460,732 total beneficiaries, 678,730 patients were identified with baseline asthma and more often identified as Black or Hispanic, were Medicaid eligible, or resided in a highly disadvantaged neighborhood than those without asthma. Two-year incidence of AD was 1.4% with asthma vs 1.1% without; prevalence was 7.8% vs 5.4% (both p=<0.001). Per 100,000 patients over two years, 303 more incident AD diagnoses occurred in asthma, with 2,425 more prevalent cases (p<0.001). Multivariable models showed asthma had greater odds of two-year AD incidence [AOR 1.33 (1.29-1.36); matched 1.2 (1.17-1.24)] and prevalence [AOR 1.48 (1.47-1.50); matched 1.25 (1.22-1.27)).

CONCLUSION

Asthma was associated with 20-33% increased two-year incidence and 25-48% increased prevalence of claims-based Alzheimer's disease in this nationally representative US sample. Future research should investigate risk pathways of underlying comorbidities and social determinants, as well as whether there are potential asthma treatments that may preserve brain health.

Receipt of rheumatology care and lupus-specific labs among young adults with systemic lupus erythematosus: A US Medicare retention in care cohort study

OBJECTIVE

In systemic lupus erythematosus, poor disease outcomes occur in young adults, patients identifying as Black or Hispanic, and socioeconomically disadvantaged patients. These identities and social factors differentially shape care access and quality that contribute to lupus health disparities in the US. Thus, our objective was to measure markers of care access and quality, including rheumatology visits (longitudinal care retention) and lupus-specific serology testing, by race and ethnicity, neighborhood disadvantage, and geographic context.

METHODS

This cohort study used a geo-linked 20% national sample of young adult Medicare beneficiaries (ages 18-35) with lupus-coded encounters and a 1-year assessment period. Retention in lupus care required a rheumatology visit in each 6-month period, and serology testing required ≥1 complement or dsDNA antibody test within the year. Multivariable logistic regression models were fit for visit-based retention and serology testing to determine associations with race and ethnicity, neighborhood disadvantage, and geography.

RESULTS

Among 1,036 young adults with lupus, 39% saw a rheumatologist every 6 months and 28% had serology testing. White beneficiaries from the least disadvantaged quintile of neighborhoods had higher visit-based retention than other beneficiaries (64% vs 30%-60%). Serology testing decreased with increasing neighborhood disadvantage quintile (aOR 0.80; 95% CI 0.71, 0.90) and in the Midwest (aOR 0.46; 0.30, 0.71).

CONCLUSION

Disparities in care, measured by rheumatology visits and serology testing, exist by neighborhood disadvantage, race and ethnicity, and region among young adults with lupus, despite uniform Medicare coverage. Findings support evaluating lupus care quality measures and their impact on US lupus outcomes.

Association between military service and Alzheimer's disease neuropathology at autopsy

INTRODUCTION

Anti-amyloid therapies are at the forefront of efforts to treat Alzheimer's disease (AD). Identifying amyloid risk factors may aid screening and intervention strategies. While veterans face increased exposure to risk factors, whether they face a greater neuropathologic amyloid burden is not well understood.

METHODS

Male decedents donating to two Alzheimer's Disease Research Center (ADRC) brain banks from 1986 to 2018 with categorized neuritic plaque density and neurofibrillary tangles (n = 597) were included. Using generalized ordered logistic regression we modeled each outcome's association with military history adjusting for age and death year.

RESULTS

Having served in the military (60% of sample) is associated with post mortem neuritic amyloid plaque (for each comparison of higher to lower C scores OR = 1.26; 95% confidence interval [CI] = 1.06-1.49) and tau pathology (B score OR = 1.10; 95% CI = 1.08-1.12).

DISCUSSION

This is the first study, to our knowledge, finding increased levels of verified AD neuropathology in those with military service. Targeted veteran AD therapies is a pressing need.

Stratifying Risk of Nonadherence in Lingual Strengthening Dysphagia Rehabilitation

PURPOSE

Exercise-based treatments may improve swallowing safety and efficiency; yet, it is not clearly understood which factors predict nonadherence to recommended treatment protocols. The aim of this study was to construct an algorithm for stratifying risk of nonadherence to a lingual strengthening dysphagia treatment program.

METHOD

Using recursive partitioning, we created a classification tree built from a pool of sociodemographic, clinical, and functional status indicators to identify risk groups for nonadherence to an intensive lingual strengthening treatment program. Nonadherence, or noncompletion, was defined as not completing two or more follow-up sessions or a final session within 84 days.

RESULTS

The study cohort consisted of 243 Veterans enrolled in the Intensive Dysphagia Treatment program across six sites from January 2012 to August 2019. The overall rate of nonadherence in this cohort was 38%. The classification tree demonstrated good discriminate validity (C-statistic = 0.74) and contained eight groups from five variables: primary diagnosis, marital status, Penetration-Aspiration Scale (PAS) severity score, race/ethnicity, and age. Nonadherence risk was categorized as high (range: 69%-77%), intermediate (27%-33%), and low risk (≤ 13%-22%).

CONCLUSIONS

This study identified distinct risk groups for nonadherence to lingual strengthening dysphagia rehabilitation. Additional research is necessary to understand how these factors may drive nonadherence. With external validation and refinement through prospective studies, a clinically relevant risk stratification tool can be developed to identify patients who may be at high risk for nonadherence and provide targeted patient support to mitigate risk and provide for unmet needs.

Associations of Postdischarge Follow-Up With Acute Care and Mortality in Lupus: A Medicare Cohort Study

OBJECTIVE

Patients with systemic lupus erythematosus experience the sixth highest rate of 30-day readmissions among chronic diseases. Timely postdischarge follow-up is a marker of ambulatory care quality that can reduce readmissions in other chronic conditions. Our objective was to test the hypotheses that 1) beneficiaries from populations experiencing health disparities, including patients from disadvantaged neighborhoods, will have lower odds of completed follow-up, and that 2) follow-up will predict longer time without acute care use (readmission, observation stay, or emergency department visit) or mortality.

METHODS

This observational cohort study included hospitalizations in January-November 2014 from a 20% random sample of Medicare adults. Included hospitalizations had a lupus code, discharge to home without hospice, and continuous Medicare A/B coverage for 1 year before and 1 month after hospitalization. Timely follow-up included visits with primary care or rheumatology within 30 days. Thirty-day survival outcomes were acute care use and mortality adjusted for sociodemographic information and comorbidities.

RESULTS

Over one-third (35%) of lupus hospitalizations lacked 30-day follow-up. Younger age, living in disadvantaged neighborhoods, and rurality were associated with lower odds of follow-up. Follow-up was not associated with subsequent acute care or mortality in beneficiaries age <65 years. In contrast, follow-up was associated with a 27% higher hazard for acute care use (adjusted hazard ratio [HR] 1.27 [95% confidence interval (95% CI) 1.09-1.47]) and 65% lower mortality (adjusted HR 0.35 [95% CI 0.19-0.67]) among beneficiaries age ≥65 years.

CONCLUSION

One-third of lupus hospitalizations lacked follow-up, with significant disparities in rural and disadvantaged neighborhoods. Follow-up was associated with increased acute care, but 65% lower mortality in older systemic lupus erythematosus patients. Further development of lupus-specific postdischarge strategies is needed.

Association of rurality and identifying as black with receipt of specialty care among patients hospitalized with a diabetic foot ulcer: a Medicare cohort study

INTRODUCTION

Rural patients with diabetic foot ulcers, especially those identifying as black, face increased risk of major amputation. Specialty care can reduce this risk. However, care disparities might beget outcome disparities. We aimed to determine whether a smaller proportion of rural patients, particularly those identifying as black, receive specialty care compared with the national proportion.

RESEARCH DESIGN AND METHODS

This 100% national retrospective cohort examined Medicare beneficiaries hospitalized with diabetic foot ulcers (2013-2014). We report observed differences in specialty care, including: endocrinology, infectious disease, orthopedic surgery, plastic surgery, podiatry, or vascular surgery. We used logistic regression to examine possible intersectionality between rurality and race, controlling for sociodemographics, comorbidities, and ulcer severity and including an interaction term between rurality and identifying as black.

RESULTS

Overall, 32.15% (n=124 487) of patients hospitalized with a diabetic foot ulcer received specialty care. Among rural patients (n=13 100), the proportion decreased to 29.57%. For patients identifying as black (n=21 649), the proportion was 33.08%. Among rural patients identifying as black (n=1239), 26.23% received specialty care. This was >5 absolute percentage points less than the overall cohort. The adjusted OR for receiving specialty care among rural versus urban patients identifying as black was 0.61 (95% CI 0.53 to 0.71), which was lower than that for rural versus urban patients identifying as white (aOR 0.85, 95% CI 0.80 to 0.89). This metric supported a role for intersectionality between rurality and identifying as black.

CONCLUSIONS

A smaller proportion of rural patients, particularly those identifying as black, received specialty care when hospitalized with a diabetic foot ulcer compared with the overall cohort. This might contribute to known disparities in major amputations. Future studies are needed to determine causality.

Disparities in 30-day readmission rates among Medicare enrollees with dementia

BACKGROUND

Readmissions contribute to excessive care costs and burden for people living with dementia. Assessments of racial disparities in readmissions among dementia populations are lacking, and the role of social and geographic risk factors such as individual-level exposure to greater neighborhood disadvantage is poorly understood. We examined the association between race and 30-day readmissions in a nationally representative sample of Black and non-Hispanic White individuals with dementia diagnoses.

METHODS

This retrospective cohort study used 100% Medicare fee-for-service claims from all 2014 hospitalizations nationwide among Medicare enrollees with dementia diagnosis linked to patient, stay, and hospital factors. The sample consisted of 1,523,142 hospital stays among 945,481 beneficiaries. The relationship between all cause 30-day readmissions and the explanatory variable of self-reported race (Black, non-Hispanic White) was examined via generalized estimating equations approach adjusting for patient, stay, and hospital-level characteristics to model 30-day readmission odds.

RESULTS

Black Medicare beneficiaries had 37% higher readmission odds compared to White beneficiaries (unadjusted OR 1.37, CI 1.35-1.39). This heightened readmission risk persisted after adjusting for geographic factors (OR 1.33, CI 1.31-1.34), social factors (OR 1.25, CI 1.23-1.27), hospital characteristics (OR 1.24, CI 1.23-1.26), stay-level factors (OR 1.22, CI 1.21-1.24), demographics (OR 1.21, CI 1.19-1.23), and comorbidities (OR 1.16, CI 1.14-1.17), suggesting racially-patterned disparities in care account for a portion of observed differences. Associations varied by individual-level exposure to neighborhood disadvantage such that the protective effect of living in a less disadvantaged neighborhood was associated with reduced readmissions for White but not Black beneficiaries. Conversely, among White beneficiaries, exposure to the most disadvantaged neighborhoods associated with greater readmission rates compared to White beneficiaries residing in less disadvantaged contexts.

CONCLUSIONS

There are significant racial and geographic disparities in 30-day readmission rates among Medicare beneficiaries with dementia diagnoses. Findings suggest distinct mechanisms underlying observed disparities differentially influence various subpopulations.

Age-Stratified 30-day Rehospitalization and Mortality and Predictors of Rehospitalization Among Patients With Systemic Lupus Erythematosus: A Medicare Cohort Study

OBJECTIVE

Recent studies suggest young adults with systemic lupus erythematosus (SLE) have high 30-day readmission rates, which may necessitate tailored readmission reduction strategies. To aid in risk stratification for future strategies, we measured 30-day rehospitalization and mortality rates among Medicare beneficiaries with SLE and determined rehospitalization predictors by age.

METHODS

In a 2014 20% national Medicare sample of hospitalizations, rehospitalization risk and mortality within 30 days of discharge were calculated for young (aged 18-35 yrs), middle-aged (aged 36-64 yrs), and older (aged 65+ yrs) beneficiaries with and without SLE. Multivariable generalized estimating equation models were used to predict rehospitalization rates among patients with SLE by age group using patient, hospital, and geographic factors.

RESULTS

Among 1.39 million Medicare hospitalizations, 10,868 involved beneficiaries with SLE. Hospitalized young adult beneficiaries with SLE were more racially diverse, were living in more disadvantaged areas, and had more comorbidities than older beneficiaries with SLE and those without SLE. Thirty-day rehospitalization was 36% among young adult beneficiaries with SLE-40% higher than peers without SLE and 85% higher than older beneficiaries with SLE. Longer length of stay and higher comorbidity risk score increased odds of rehospitalization in all age groups, whereas specific comorbid condition predictors and their effect varied. Our models, which incorporated neighborhood-level socioeconomic disadvantage, had moderate-to-good predictive value (C statistics 0.67-0.77), outperforming administrative data models lacking comprehensive social determinants in other conditions.

CONCLUSION

Young adults with SLE on Medicare had very high 30-day rehospitalization at 36%. Considering socioeconomic disadvantage and comorbidities provided good prediction of rehospitalization risk, particularly in young adults. Young beneficiaries with SLE with comorbidities should be a focus of programs aimed at reducing rehospitalizations.

Race, Sex, and Neighborhood Socioeconomic Disparities in Ablation of Ventricular Tachycardia Within a National Medicare Cohort

Background Ventricular tachycardia (VT) ablation significantly improves our ability to control VT, yet little is known about whether disparities exist in delivery of this technology. Methods and Results Using a national 100% Medicare inpatient data set of beneficiaries admitted with VT from January 1, 2014, through November 30, 2014, multivariable logistic regression techniques were used to examine the sociodemographic and clinical characteristics associated with receiving ablation. Census block group-level neighborhood socioeconomic disadvantage was measured for each patient by the Area Deprivation Index, a composite measure of socioeconomic disadvantage consisting of education, income, housing, and employment factors. Among 131 645 patients admitted with VT, 2190 (1.66%) received ablation. After adjustment for comorbidities, hospital characteristics, and sociodemographics, female sex (odds ratio [OR], 0.75 [95% CI, 0.67-0.84]), identifying as Black race (OR, 0.75 [95% CI, 0.62-0.90] compared with identifying as White race), and living in a highly socioeconomically disadvantaged neighborhood (national Area Deprivation Index percentile of >85%) (OR, 0.81 [95% CI, 0.69-0.95] versus Area Deprivation Index ≤85%) were associated with significantly lower odds of receiving ablation. Conclusions Female patients, patients identifying as Black race, and patients living in the most disadvantaged neighborhoods are 19% to 25% less likely to receive ablation during hospitalization with VT. The cause of and solutions for these disparities require further investigation.

Association of Neighborhood-Level Disadvantage With Neurofibrillary Tangles on Neuropathological Tissue Assessment

This cross-sectional study evaluates income, educational level, employment status, and neighborhood and their association with brain changes in decedents with Alzheimer disease and related dementias.

Evaluating How Safety-Net Hospitals Are Identified: Systematic Review and Recommendations

Objective:

To systematically review how safety-net hospitals' status is identified and defined, discuss current definitions' limitations, and provide recommendations for a new classification and evaluation framework.

Data Sources:

Safety-net hospital-related studies in the MEDLINE database published before May 16, 2019.

Study Design:

Systematic review of the literature that adheres to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines.

Data Collection/Extraction Methods:

We followed standard selection protocol, whereby studies went through an abstract review followed by a full-text screening for eligibility. For each included study, we extracted information about the identification method itself, including the operational definition, the dimension(s) of disadvantage reflected, study objective, and how safety-net status was evaluated.

Principal Findings:

Our review identified 132 studies investigating safety-net hospitals. Analysis of identification methodologies revealed substantial heterogeneity in the ways disadvantage is defined, measured, and summarized at the hospital level, despite a 4.5-fold increase in studies investigating safety-net hospitals for the past decade. Definitions often exclusively used low-income proxies captured within existing health system data, rarely incorporated external social risk factor measures, and were commonly separated into distinct safety-net status categories when analyzed.

Conclusions:

Consistency in research and improvement in policy both require a standard definition for identifying safety-net hospitals. Yet no standardized definition of safety-net hospitals is endorsed and existing definitions have key limitations. Moving forward, approaches rooted in health equity theory can provide a more holistic framework for evaluating disadvantage at the hospital level. Furthermore, advancements in precision public health technologies make it easier to incorporate detailed neighborhood-level social determinants of health metrics into multidimensional definitions. Other countries, including the United Kingdom and New Zealand, have used similar methods of identifying social need to determine more accurate assessments of hospital performance and the development of policies and targeted programs for improving outcomes.

Association of Race, Ethnicity, and Rurality With Major Leg Amputation or Death Among Medicare Beneficiaries Hospitalized With Diabetic Foot Ulcers

IMPORTANCE

Patients identifying as Black and those living in rural and disadvantaged neighborhoods are at increased risk of major (above-ankle) leg amputations owing to diabetic foot ulcers. Intersectionality emphasizes that the disparities faced by multiply marginalized people (eg, rural US individuals identifying as Black) are greater than the sum of each individual disparity.

OBJECTIVE

To assess whether intersecting identities of Black race, ethnicity, rural residence, or living in a disadvantaged neighborhood are associated with increased risk in major leg amputation or death among Medicare beneficiaries hospitalized with diabetic foot ulcers.

DESIGN, SETTING, AND PARTICIPANTS

This retrospective cohort study used 2013-2014 data from the US National Medicare Claims Data Database on all adult Medicare patients hospitalized with a diabetic foot ulcer. Statistical analysis was conducted from August 1 to October 27, 2021.

EXPOSURES

Race was categorized using Research Triangle Institute variables. Rurality was assigned using Rural-Urban Commuting Area codes. Residents of disadvantaged neighborhoods comprised those living in neighborhoods at or above the national 80th percentile Area Deprivation Index.

MAIN OUTCOMES AND MEASURES

Major leg amputation or death during hospitalization or within 30 days of hospital discharge. Logistic regression was used to explore interactions among race, ethnicity, rurality, and neighborhood disadvantage, controlling for sociodemographic characteristics, comorbidities, and ulcer severity.

RESULTS

The cohort included 124 487 patients, with a mean (SD) age of 71.5 (13.0) years, of whom 71 286 (57.3%) were men, 13 100 (10.5%) were rural, and 21 649 (17.4%) identified as Black. Overall, 17.6% of the cohort (n = 21 919), 18.3% of rural patients (2402 of 13 100), and 21.9% of patients identifying as Black (4732 of 21 649) underwent major leg amputation or died. Among 1239 rural patients identifying as Black, this proportion was 28.0% (n = 347). This proportion exceeded the expected excess for rural patients (18.3% - 17.6% = 0.7%) plus those identifying as Black (21.9% - 17.6% = 4.3%) by more than 2-fold (28.0% - 17.6% = 10.4% vs 0.7% + 4.3% = 5.0%). The adjusted predicted probability of major leg amputation or death remained high at 24.7% (95% CI, 22.4%-26.9%), with a significant interaction between race and rurality.

CONCLUSIONS AND RELEVANCE

Rural patients identifying as Black had a more than 10% absolute increased risk of major leg amputation or death compared with the overall cohort. This study suggests that racial and rural disparities interacted, amplifying risk. Findings support using an intersectionality lens to investigate and address disparities in major leg amputation and mortality for patients with diabetic foot ulcers.

Hospital Characteristics by Proportion of Patients from Disadvantaged Neighborhoods

Neighborhood disadvantage reflects historic and ongoing systemic injustices. Without addressing these upstream social determinants of health, hospitals may face different risk profiles for important quality metrics. Our objective was to assess differences in hospital characteristics where the proportion of patients residing in severely disadvantaged neighborhoods was high vs low. Using Medicare fee-for-service claims between January 1, 2014 and November 30, 2014 (5,807,499 hospital stays), we calculated Area Disadvantage Share (ADS), the proportion of each hospital's discharges to severely disadvantaged neighborhoods, for 4,528 hospitals. We examined hospital characteristics by distribution of ADS and by risk-adjusted 30-day readmission. Hospitals in the highest decile cared for a higher proportion of Black patients, were more often located in rural areas, and had higher patient risk of 30-day readmission compared to all other deciles. Hospitals face unequal burdens of neighborhood disadvantage, a factor distinct from other social determinants such as rurality.

A Scoping Review of the Association of Social Disadvantage and Cerebrovascular Disease Confirmed by Neuroimaging and Neuropathology

Social disadvantage—a state of low-income, limited education, poor living conditions, or limited social support—mediates chronic health conditions, including cerebrovascular disease. Social disadvantage is a key component in several health impact frameworks, providing explanations for how individual-level factors interact with interpersonal and environmental factors to create health disparities. Understanding the association between social disadvantage and vascular neuropathology, brain lesions identified by neuroimaging and autopsy, could provide insight into how one’s social context interacts with biological processes to produce disease. The goal of this scoping review was to evaluate the scientific literature on the relationship between social disadvantage and cerebrovascular disease, confirmed through assessment of vascular neuropathology. We reviewed 4049 titles and abstracts returned from our search and included records for full-text review that evaluated a measure of social disadvantage as an exposure variable and cerebrovascular disease, confirmed through assessment of vascular neuropathology, as an outcome measure. We extracted exposures and outcomes from 20 articles meeting the criteria after full-text review, and described the study findings and populations sampled. An improved understanding of the link between social factors and cerebrovascular disease will be an important step in moving the field closer to addressing the fundamental causes of disease and towards more equitable brain health.

The Hospital Readmissions Reduction Program and Observation Hospitalizations

The Centers for Medicare & Medicaid Services (CMS) Hospital Readmissions Reduction Program (HRRP) penalizes hospitals having excess inpatient rehospitalizations within 30 days of index inpatient stays for targeted conditions. Observation hospitalizations are increasing in frequency and may clinically resemble inpatient hospitalizations, yet HRRP excludes observation in index and 30-day rehospitalization counts. Using 100% 2014 Medicare fee-for-service claims and CMS's 30-day rehospitalization methodology, we modeled how observation hospitalizations impact HRRP metrics when counted as index (denominator) and 30-day (numerator) rehospitalizations. Of 3,806,772 index hospitalizations for HRRP conditions, 418,923 (11%) were observation; 18% (155,553/876,033) of rehospitalizations were invisible to HRRP due to observation hospitalization as index (34%; 63,740/188,430), 30-day outcome (53%; 100,343/188,430), or both (13%; 24,347/188,430). By ignoring observation hospitalizations as index and 30-day events, nearly one of five HRRP rehospitalizations is missed. Policymakers might consider this an opportunity to address broad challenges of the two-tiered observation and inpatient hospital billing distinction.

One Quarter of Medicare Hospitalizations in Patients with Systemic Lupus Erythematosus Readmitted within Thirty Days

OBJECTIVE

Thirty-day hospital readmissions in systemic lupus erythematosus (SLE) approach proportions in Medicare-reported conditions including heart failure (HF). We compared adjusted 30-day readmission and mortality among SLE, HF, and general Medicare to assess predictors informing readmission prevention.

METHODS

This database study used a 20% sample of all US Medicare 2014 adult hospitalizations to compare risk of 30-day readmission and mortality among admissions with SLE, HF, and neither per discharge diagnoses (if both SLE and HF, classified as SLE). Inclusion required live discharge and ≥12 months of Medicare A/B before admission to assess baseline covariates including patient, geographic, and hospital factors. Analysis used observed and predicted probabilities, and multivariable GEE models clustered by patient to report adjusted risk ratios (ARRs) of 30-day readmission and mortality.

RESULTS

SLE admissions (n=10,868) were younger, predominantly female, more likely to be Black, disabled, and have Medicaid or end-stage renal disease (ESRD). Observed 30-day readmissions of 24% were identical for SLE and HF (p = 0.6), and higher than other Medicare (16%, p < 0.001). Both SLE and HF had elevated readmission risk (ARR 1.08, (95% CI (1.04, 1.13)); 1.11, (1.09, 1.13)). SLE readmissions were higher for Black (30%) versus White (21%) populations, and highest in ages 18-33 (39%) and ESRD (37%). Admissions of Black patients with SLE from least disadvantaged neighborhoods had highest 30-day mortality (9% versus 3% White).

CONCLUSION

Thirty-day SLE readmissions rivaled HF at 24%. Readmission prevention programs should engage young, ESRD patients with SLE and examine potential causal gaps in SLE care and transitions.

Thirty-Day Re-observation, Chronic Re-observation, and Neighborhood Disadvantage

OBJECTIVE

To determine whether neighborhood socioeconomic disadvantage, as determined by the Area Deprivation Index, increases 30-day hospital re-observation risk.

PARTICIPANTS AND METHODS

This retrospective study of 20% Medicare fee-for-service beneficiary observation stays from January 1, 2014, to November 30, 2014, included 319,980 stays among 273,308 beneficiaries. We evaluated risk for a 30-day re-observation following an index observation stay for those living in the 15% most disadvantaged compared with the 85% least disadvantaged neighborhoods.

RESULTS

Overall, 4.5% (270,600 of 6,080,664) of beneficiaries had index observation stays, which varied by disadvantage (4.3% [232,568 of 5,398,311] in the least disadvantaged 85% compared with 5.6% [38,032 of 682,353] in the most disadvantaged 15%). Patients in the most disadvantaged neighborhoods had a higher 30-day re-observation rate (2857 of 41,975; 6.8%) compared with least disadvantaged neighborhoods (13,543 of 278,005; 4.9%); a 43% increased risk (unadjusted odds ratio [OR], 1.43; 95% CI, 1.31 to 1.55). After adjustment, this risk remained (adjusted OR, 1.13; 95% CI, 1.04 to 1.22). Discharge to a skilled nursing facility reduced 30-day re-observation risk (OR, 0.63; 95% CI, 0.57 to 0.69), whereas index observation length of stay of 4 or more days (3 midnights) conferred increased risk (OR, 1.29; 95% CI, 1.09 to 1.52); those living in disadvantaged neighborhoods were less likely to discharge to skilled nursing facilities and more likely to have long index stays. Beneficiaries with more than one 30-day re-observation (chronic re-observation) had progressively greater disadvantage by number of stays (adjusted incident rate ratio, 1.08; 95% CI, 1.02 to 1.14). Observation prevalence varied nationally.

CONCLUSION

Thirty-day re-observation, especially chronic re-observation, is highly associated with socioeconomic neighborhood disadvantage, even after accounting for factors such as race, disability, and Medicaid eligibility. Beneficiaries least able to pay are potentially most vulnerable to costs from serial re-observations and challenges of Medicare observation policy, which may discourage patients from seeking necessary care.

Neighborhood disadvantage and 30-day readmission risk following Clostridioides difficile infection hospitalization

BACKGROUND

Clostridioides difficile infection (CDI) is commonly associated with outcomes like recurrence and readmission. The effect of social determinants of health, such as 'neighborhood' socioeconomic disadvantage, on a CDI patient's health outcomes is unclear. Living in a disadvantaged neighborhood could interfere with a CDI patient's ability to follow post-discharge care recommendations and the success probability of these recommendations, thereby increasing risk of readmission. We hypothesized that neighborhood disadvantage was associated with 30-day readmission risk in Medicare patients with CDI.

METHODS

In this retrospective cohort study, odds of 30-day readmission for CDI patients are evaluated controlling for patient sociodemographics, comorbidities, and hospital and stay-level variables. The cohort was created from a random 20% national sample of Medicare patients during the first 11 months of 2014.

RESULTS

From the cohort of 19,490 patients (39% male; 80% white; 83% 65 years or older), 22% were readmitted within 30 days of an index stay. Unadjusted analyses showed that patients from the most disadvantaged neighborhoods were readmitted at a higher rate than those from less disadvantaged neighborhoods (26% vs. 21% rate: unadjusted OR = 1.32 [1.20, 1.45]). This relationship held in adjusted analyses, in which residence in the most disadvantaged neighborhoods was associated with 16% increased odds of readmission (adjusted OR = 1.16 [1.04, 1.28]).

CONCLUSIONS

Residence in disadvantaged neighborhoods poses a significantly increased risk of readmission in CDI patients. Further research should focus on in-depth assessments of this population to better understand the mechanisms underlying these risks and if these findings apply to other infectious diseases.

Improving Healthcare Value: COVID-19 Emergency Regulatory Relief and Implications for Post-Acute Skilled Nursing Facility Care

Rarely, if ever, does a national healthcare system experience such rapid and marked change as that seen with the COVID-19 pandemic. In March 2020, the president of the United States declared a national health emergency, enabling the Department of Health & Human Services authority to grant temporary regulatory waivers to facilitate efficient care delivery in a variety of healthcare settings. The statutory requirement that Medicare beneficiaries stay three consecutive inpatient midnights to qualify for post-acute skilled nursing facility coverage is one such waiver. This so-called Three Midnight Rule, dating back to the 1960s as part of the Social Security Act, is being scrutinized more than half a century later given the rise in observation hospital stays. Despite the tragic emergency circumstances prompting waivers, the Centers for Medicare & Medicaid Services and Congress now have a unique opportunity to evaluate potential improvements revealed by COVID-19 regulatory relief and should consider permanent reform of the Three Midnight Rule.

Association of Neighborhood-Level Disadvantage With Alzheimer Disease Neuropathology

IMPORTANCE

Social determinants of health, such as income, education, housing quality, and employment, are associated with disparities in Alzheimer disease and health generally, yet these determinants are rarely incorporated within neuropathology research.

OBJECTIVE

To establish the feasibility of linking neuropathology data to social determinants of health exposures using neighborhood disadvantage metrics (the validated Area Deprivation Index) and to evaluate the association between neighborhood disadvantage and Alzheimer disease-related neuropathology.

DESIGN, SETTING, AND PARTICIPANTS

This cross-sectional study consisted of decedents with a known home address who donated their brains to 1 of 2 Alzheimer disease research center brain banks in California and Wisconsin between January 1, 1990, and December 31, 2016. Neither site had preexisting social metrics available for their decedents. Neuropathologic features were obtained from each site for data collected using the standardized Neuropathology Data Set form and from autopsy reports. Data were analyzed from June 7 to October 10, 2019.

EXPOSURES

Geocoded decedent addresses linked to neighborhood disadvantage as measured by the Area Deprivation Index calculated for the year of death.

MAIN OUTCOMES AND MEASURES

Presence of Alzheimer disease neuropathology. The association between neighborhood disadvantage and Alzheimer disease neuropathology was evaluated via logistic regression, adjusting for age, sex, and year of death.

RESULTS

The sample consisted of 447 decedents (249 men [56%]; mean [SD] age, 80.3 [9.5] years; median year of death, 2011) spanning 24 years of donation. Fewer decedents (n = 24 [5.4%]) originated from the top 20% most disadvantaged neighborhood contexts. Increasing neighborhood disadvantage was associated with an 8.1% increase in the odds of Alzheimer disease neuropathology for every decile change on the Area Deprivation Index (adjusted odds ratio, 1.08; 95% CI, 1.07-1.09). As such, living in the most disadvantaged neighborhood decile was associated with a 2.18 increased odds of Alzheimer disease neuropathology (adjusted odds ratio, 2.18; 95% CI, 1.99-2.39).

CONCLUSIONS AND RELEVANCE

The findings of this cross-sectional study suggest that social determinants of health data can be linked to preexisting autopsy samples as a means to study sociobiological mechanisms involved in neuropathology. This novel technique has the potential to be applied to any brain bank within the United States. To our knowledge, this is the first time Alzheimer disease neuropathology has been associated with neighborhood disadvantage.

What Is an Observation Stay? Evaluating the Use of Hospital Observation Stays in Medicare

BACKGROUND/OBJECTIVES

Observation stays are increasingly common for older adults, yet little is known about the extent to which they are being used as the Centers for Medicare and Medicaid Services (CMS) originally intended for unscheduled or acute problems and whether different types of services are reflected in current billing practices.

DESIGN

Observational cohort study.

SETTING/PARTICIPANTS

A total of 867,165 qualifying observation stays identified from 451,408 patients using Medicare fee-for-service claims data from a nationally representative 20% beneficiary sample between January 1, 2014, and November 30, 2014.

MEASUREMENTS

Using descriptive and multivariable logistic model analytic approaches, we evaluated the patient, stay, and hospital characteristics associated with the most common billing practice for observation stays (charge revenue center 0761 exclusively) vs all other practices.

RESULTS

Sixty-three percent of observation stays were billed exclusively under the 0761 revenue center and were more likely to be for preplanned chronic conditions consisting of short-term treatments (eg, chemotherapy, radiation therapy, wound care, paracentesis, epidural spinal injection). These stays appeared to be used for recurrent single-day visits, given their strong association with prior visits and a high rate of reobservation (41.4%), with frequent return stays appearing in a 7-day pattern.

CONCLUSION

Nearly two-thirds of observation stays are billed using only the 0761 revenue code and appear to be for prescheduled, repeated treatments-differing substantially from CMS' explicitly stated purpose as a form of care used while a healthcare provider determines whether a patient presenting for unscheduled or acute conditions requires inpatient hospital admission or can be safely discharged. Guidance is needed from CMS to clarify the appropriate role of observation stays, with discussion as to whether episodic single-day, planned treatment for chronic conditions not originating in the emergency department should be billed as observation stays or placed under another mechanism. Subsequent research is needed to understand how the current use of observation stays impact patient out-of-pocket costs. J Am Geriatr Soc 68:1568-1572, 2020.

Long-term comparative safety analysis of the risks associated with adding or switching to a sulfonylurea as second-line Type 2 diabetes mellitus treatment in a US veteran population

AIM

To examine the risks of all-cause mortality and cardiovascular events associated with adding vs switching to second-line therapies in a comparative safety study of people with Type 2 diabetes mellitus.

METHODS

We conducted a retrospective cohort study using an as-treated analysis of people served by the Veterans Health Administration who were on metformin and subsequently augmented this treatment or switched to other oral glucose-lowering treatments between 1998 and 2012. This study included 145 250 people with long follow-up. Confounding was addressed through several strategies, involving weighted propensity score models with rich confounder adjustment and strict inclusion criteria, coupled with an incident-user design.

RESULTS

Second-line use of sulfonylureas was related to higher mortality (hazard ratio 1.39, 95% CI 1.14, 1.70) and cardiovascular risks (hazard ratio 1.19, 95% CI 1.09, 1.30) compared with thiazolidinedione therapy. Differential hazards were associated with discontinuing or not discontinuing metformin; switching to sulfonylurea therapy was associated with a higher risk of all-cause mortality and cardiovascular events compared with all other therapies. Furthermore, add-on sulfonylurea therapy was associated with an elevated risk for both outcomes when compared with thiazolidinedione add-on therapy.

CONCLUSIONS

The results of the present study may inform decisions on whether to augment or discontinue metformin; when considering the long-term risks, switching to a sulfonylurea appears unfavourable compared with other therapies. Instead, adding a thiazolidinedione to existing metformin therapy appears to be superior to adding or switching to a sulfonylurea.

Meta-Analysis of Sulfonylurea Therapy on Long-Term Risk of Mortality and Cardiovascular Events Compared to Other Oral Glucose-Lowering Treatments

INTRODUCTION

Among the most pressing clinical decisions in type 2 diabetes treatments are which drugs should be used after metformin is no longer sufficient, and whether sulfonylureas (SUs) should remain as a suitable second-line treatment. In this article we summarize current evidence on the long-term safety risks associated with SU therapy relative to other oral glucose-lowering therapies.

METHODS

The MEDLINE database and Clinicaltrials.gov were searched for observational and experimental studies comparing the safety of SUs to that of other diabetes medications in people with type 2 diabetes mellitus through December 15, 2015. Studies with at least 1 year of follow-up, which explicitly examined major cardiovascular events or death in patients who showed no evidence of serious conditions at baseline, were selected for inclusion in meta-analyses.

RESULTS

SU treatment was associated with an elevated risk relative to treatment with metformin (METF), thiazolidinedione (TZD), dipeptidyl peptidase-4 inhibitor (DPP-4), and glucagon-like peptide-1 (GLP-1) agonist classes, either when compared alone (as a monotherapy) or when used in combination with METF. Significant findings were almost entirely derived from nontrial data and not confirmed by smaller, efficacy designed randomized controlled trials whose effects were in the same direction but much more imprecise.

CONCLUSION

Although much of the evidence is derived and will continue to come from observational studies, the methodological rigor of such studies is questionable. A key challenge for evaluators is the extent to which they should incorporate evidence from study designs that are quasi-experimental.

The use of contextual cues to improve warning symbol comprehension: making the connection for older adults

This study teased apart the effects of comprehensibility and complexity on older adults' comprehension of warning symbols by manipulating the relevance of additional information in further refining the meaning of the symbol. Symbols were systematically altered such that increased visual complexity (in the form of contextual cues) resulted in increased comprehensibility. One hundred older adults, aged 50-71 years, were tested on their comprehension of these symbols before and after training. High comprehensibility-complexity symbols were found to be better understood than low- or medium-comprehensibility-complexity symbols and the effectiveness of the contextual cues varied as a function of training. Therefore, the nature of additional detail determines whether increased complexity is detrimental or beneficial to older adults' comprehension - if the additional details provide 'cues to knowledge', older adults' comprehension improves as a result of the increased complexity. However, some cues may require training in order to be effective.

PRACTITIONER SUMMARY

Research suggests that older adults have greater difficulty in understanding more complex symbols. However, we found that when the complexity of symbols was increased through the addition of contextual cues, older adults' comprehension actually improved. Contextual cues aid older adults in making the connection between the symbol and its referent.

Age-related differences in warning symbol comprehension and training effectiveness: effects of familiarity, complexity, and comprehensibility

Age-related changes in selective attention, inhibitory efficiency, and the ability to form new associations suggest that older adults may have greater difficulty with more complex and less comprehensible symbols. We examined comprehension of symbols varying in terms of ratings of familiarity, complexity, and comprehensibility, by younger (aged 18-35) and older (aged 55-70) adults. It was found that older adults have greater difficulty than younger adults in comprehending warning symbols and that accident scenario training improves comprehension. Regression analyses indicated that familiarity and comprehensibility were important in determining performance on the pre-training comprehension test by both younger and older adults. However, training eliminated the effects of stimulus characteristics for younger adults, while older adults' comprehension continued to be significantly influenced by comprehensibility. We suggest that symbol design incorporates cues to knowledge to facilitate the linkage between new knowledge (i.e. the warning symbol) and relevant knowledge in long-term memory. Statement of Relevance: Symbol characteristics play an important role in age-related differences in warning symbol comprehension. To optimise comprehension by older adults, symbols should have a clear relationship with areal-world referent. Alternatively, symbol design could incorporate cues to knowledge to facilitate the linkage between new knowledge and relevant knowledge in long-term memory.

Asymmetrical facial expressions in portraits and hemispheric laterality: a literature review

Studies of facial asymmetry have revealed that the left and the right sides of the face differ in emotional attributes. This paper reviews many of these distinctions to determine how these asymmetries influence portrait paintings. It does so by relating research involving emotional expression to aesthetic pleasantness in portraits. For example, facial expressions are often asymmetrical-the left side of the face is more emotionally expressive and more often connotes negative emotions than the right side. Interestingly, artists tend to expose more of their poser's left cheek than their right. This is significant, in that artists also portray more females than males with their left cheek exposed. Reasons for these psychological findings lead to explanations for the aesthetic leftward bias in portraiture.

Repair of coarctation of the aorta associated with intracardiac repair

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Dosimetry of a silicone breast prosthesis

Dose measurements were conducted in a phantom which simulates breast tissue and in another phantom which simulates a breast containing a silicone prosthesis. No detectable difference was found when the irradiations were carried out with tangential beams of 60Co radiation. The degree of backscatter and absorption of radiation by the prosthesis and phantom were also similar. A slight decrease in dose of approximately 8% was found at the interface between the prosthesis and muscle-equivalent material.

Absorber for solar power

A simple, economical absorber utilizing a new principle of operation to achieve very low reradiation losses while generating temperatures limited by material properties of quartz is described. Its performance is analyzed and indicates approximately 90% thermal efficiency and 73% conversion efficiency for an earth based unit with moderately concentrated (~tenfold) sunlight incident. It is consequently compatible with the most economic of concentrator mirrors (stamped) or mirrors deployable in space. Space applications are particularly attractive, as temperatures significantly below 300 K are possible and permit even higher conversion efficiency.

Transmission characteristics of specularly reflecting light pipes uniformly irradiated by obliquely inclined rays

The light-pipe efficiency or fraction of the incident energy transmitted from one end to the other is expressed as a function of the wall reflectivity rho and geometrical parameters. Light pipes with both circular and rectangular cross sections are considered. The analysis includes skew rays and is mathematically exact within the limits of geometrical optics and a constant specular wall reflectivity. The distribution along the light pipe of the average intensity incident upon the walls is also derived.

Evaluation of nonisothermal semi-infinite cylinder with specularly reflecting walls as a blackbody source

The fractional deviation from blackbody radiation due to wall emissivity modestly differing from unity and due to the presence of a temperature gradient (dT/dx) at the open end of a specularly reflecting semi-infinite cylinder of diameter D and end temperature T(1) is shown to be [Equation].

Determination of electron concentrations from two intensity measurements within the h line

A method for calculating the electron concentration il dense plasmas containing hydrogen is suggested which utilizes two intensity measurements at separate points within the profile of the H(beta) line. The relative intensity observed by two detectors is expressed as a function of the electron concentration, plasma temperature, and instrumental parameters such as resolution and wavelength separation between measurements. Electron concentrations between 10(15) cm(-3) and 10(17) cm(-3) may be read directly from graphs presented in this article.