In this series of 393 consecutive patients admitted with Covid-19 to two New York City hospitals from March 3 to March 27, a third of patients received invasive mechanical ventilation, 10% of ...patients died, and 24% were still hospitalized as of April 10.
Despite potential harm that can result from polypharmacy, real-world data on polypharmacy in the setting of heart failure (HF) are limited. We sought to address this knowledge gap by studying older ...adults hospitalized for HF derived from the REGARDS study (Reasons for Geographic and Racial Differences in Stroke).
We examined 558 older adults aged ≥65 years with adjudicated HF hospitalizations from 380 hospitals across the United States. We collected and examined data from the REGARDS baseline assessment, medical charts from HF-adjudicated hospitalizations, the American Hospital Association annual survey database, and Medicare's Hospital Compare website. We counted the number of medications taken at hospital admission and discharge; and classified each medication as HF-related, non-HF cardiovascular-related, or noncardiovascular-related.
The vast majority of participants (84% at admission and 95% at discharge) took ≥5 medications; and 42% at admission and 55% at discharge took ≥10 medications. The prevalence of taking ≥10 medications (polypharmacy) increased over the study period. As the number of total medications increased, the number of noncardiovascular medications increased more rapidly than the number of HF-related or non-HF cardiovascular medications.
Defining polypharmacy as taking ≥10 medications might be more ideal in the HF population as most patients already take ≥5 medications. Polypharmacy is common both at admission and hospital discharge, and its prevalence is rising over time. The majority of medications taken by older adults with HF are noncardiovascular medications. There is a need to develop strategies that can mitigate the negative effects of polypharmacy among older adults with HF.
Background:
Previous work found that Black patients experience worse care coordination than White patients.
Objective:
The aim was to determine if there are racial disparities in self-reported ...adverse events that could have been prevented with better communication.
Research Design:
We used data from a cross-sectional survey that was administered to participants in the Reasons for Geographic and Racial Differences in Stroke (REGARDS) study in 2017–2018.
Subjects:
REGARDS participants aged 65+ years of age who reported >1 ambulatory visits and >1 provider in the prior 12 months (thus at risk for gaps in care coordination).
Measures:
Our primary outcome was any repeat test, drug-drug interaction, or emergency department visit or hospitalization that respondents thought could have been prevented with better communication. We used Poisson models with robust standard error to determine if there were differences in preventable events by race.
Results:
Among 7568 REGARDS respondents, the mean age was 77 years (SD: 6.7), 55.4% were female, and 33.6% were Black. Black participants were significantly more likely to report any preventable adverse events compared with Whites adjusted risk ratio (aRR): 1.64; 95% confidence interval (CI): 1.42–1.89. Specifically, Blacks were more likely than Whites to report a repeat test (aRR: 1.77; 95% CI: 1.38–2.29), a drug-drug interaction (aRR: 1.76; 95% CI: 1.46–2.12), and an emergency department visit or hospitalization (aRR: 1.45; 95% CI: 1.01–2.08).
Conclusions:
Black participants were significantly more likely to report a preventable adverse event attributable to poor care coordination than White participants, independent of demographic and clinical characteristics.
Background
Whether patients’ reports of gaps in care coordination reflect clinically significant problems is unclear.
Objective
To determine any association between patient-reported gaps in care ...coordination and patient-reported preventable adverse outcomes.
Design and Participants
We administered a cross-sectional survey on experiences with healthcare to participants in the national Reasons for Geographic and Racial Differences in Stroke (REGARDS) study who were ≥ 65 years old. Of the 15,817 participants in REGARDS at the time of our survey (August 2017–November 2018), 11,138 completed the survey. We restricted the sample to participants who reported ≥ 2 ambulatory visits and ≥ 2 ambulatory providers in the past year (
N
= 7568).
Main Measures
We considered 7 gaps in ambulatory care coordination, elicited with previously validated questions. We considered 4 outcomes: (1) a test that was repeated because the doctor did not have the result of the first test, (2) a drug-drug interaction that occurred due to multiple prescribers, (3) an emergency department visit that could have been prevented by better communication among providers, and (4) a hospital admission that could have been prevented by better communication among providers. We used logistic regression to determine the association between ≥ 1 gap in care coordination and ≥ 1 preventable outcome, adjusting for potential confounders.
Key Results
The average age of the sample was 77.0 years; 55% were female, and 34% were African-American. More than one-third of participants (38.1%) reported ≥ 1 gap in care coordination and nearly one-tenth (9.8%) reported ≥ 1 preventable outcome. Having ≥ 1 gap in care coordination was associated with an increased odds of ≥ 1 preventable outcome (adjusted odds ratio 1.55; 95% confidence interval 1.33, 1.81).
Conclusions
Participants’ reports of gaps in care coordination were associated with an increased odds of preventable adverse outcomes. Future interventions should leverage patients’ observations to detect and resolve gaps in care coordination.
City-wide lockdowns and school closures have demonstrably impacted COVID-19 transmission. However, simulation studies have suggested an increased risk of COVID-19 related morbidity for older ...individuals inoculated by house-bound children. This study examines whether the March 2020 lockdown in New York City (NYC) was associated with higher COVID-19 hospitalization rates in neighborhoods with larger proportions of multigenerational households.
We obtained daily age-segmented COVID-19 hospitalization counts in each of 166 ZIP code tabulation areas (ZCTAs) in NYC. Using Bayesian Poisson regression models that account for spatiotemporal dependencies between ZCTAs, as well as socioeconomic risk factors, we conducted a difference-in-differences study amongst ZCTA-level hospitalization rates from February 23 to May 2, 2020. We compared ZCTAs in the lowest quartile of multigenerational housing to other quartiles before and after the lockdown.
Among individuals over 55 years, the lockdown was associated with higher COVID-19 hospitalization rates in ZCTAs with more multigenerational households. The greatest difference occurred three weeks after lockdown: Q2 vs. Q1: 54% increase (95% Bayesian credible intervals: 22-96%); Q3 vs. Q1: 48% (17-89%); Q4 vs. Q1: 66% (30-211%). After accounting for pandemic-related population shifts, a significant difference was observed only in Q4 ZCTAs: 37% (7-76%).
By increasing house-bound mixing across older and younger age groups, city-wide lockdown mandates imposed during the growth of COVID-19 cases may have inadvertently, but transiently, contributed to increased transmission in multigenerational households.
Celotno besedilo
Dostopno za:
DOBA, IZUM, KILJ, NUK, PILJ, PNG, SAZU, SIK, UILJ, UKNU, UL, UM, UPUK
Background
Highly fragmented ambulatory care (i.e., care spread across many providers without a dominant provider) has been associated with excess tests, procedures, emergency department visits, and ...hospitalizations. Whether fragmented care is associated with worse health outcomes, or whether any association varies with health status, is unclear.
Objective
To determine whether fragmented care is associated with the risk of incident coronary heart disease (CHD) events, overall and stratified by self-rated general health.
Design and Participants
We conducted a secondary analysis of the nationwide prospective Reasons for Geographic and Racial Differences in Stroke (REGARDS) cohort study (2003–2016). We included participants who were ≥ 65 years old, had linked Medicare fee-for-service claims, and had no history of CHD (
N
= 10,556).
Main Measures
We measured fragmentation with the reversed Bice-Boxerman Index. We used Cox proportional hazards models to determine the association between fragmentation as a time-varying exposure and adjudicated incident CHD events in the 3 months following each exposure period.
Key Results
The mean age was 70 years; 57% were women, and 34% were African-American. Over 11.8 years of follow-up, 569 participants had CHD events. Overall, the adjusted hazard ratio (HR) for the association between high fragmentation and incident CHD events was 1.14 (95% confidence interval (CI) 0.92, 1.39). Among those with very good or good self-rated health, high fragmentation was associated with an increased hazard of CHD events (adjusted HR 1.35; 95% CI 1.06, 1.73;
p
= 0.01). Among those with fair or poor self-rated health, high fragmentation was associated with a trend toward a decreased hazard of CHD events (adjusted HR 0.54; 95% CI 0.29, 1.01;
p
= 0.052). There was no association among those with excellent self-rated health.
Conclusion
High fragmentation was associated with an increased independent risk of incident CHD events among those with very good or good self-rated health.
Purpose
Cardiovascular disease (CVD) is the number one cause of death among 5-year cancer survivors. Survivors see many providers and poor coordination may contribute to worse CVD risk factor ...control. We sought to determine associations between fragmentation and CVD risk factor control among survivors overall and by self-rated health.
Methods
We included REGARDS participants aged 66+ years who (1) had a cancer history; (2) reported diabetes, hypertension, or hyperlipidemia; and (3) had continuous Medicare coverage. Twelve-month ambulatory care fragmentation was calculated using the Bice-Boxerman Index (BBI). We determined associations between fragmentation and CVD risk factors, defining “control” as fasting glucose < 126 mg/dL or non-fasting glucose < 200 mg/dL for diabetes; blood pressure < 140/90 mmHg for hypertension; and total cholesterol <240 mg/dL, low-density lipoprotein cholesterol < 160 mg/dL, or high-density lipoprotein cholesterol >40 mg/dL for hyperlipidemia.
Results
The 1002 cancer survivors (2+ years since cancer treatment) had mean age of 75 years, 39% were women, and 23% were Black. Among individuals with diabetes (
N
= 225), hypertension (
N
= 660), and hyperlipidemia (
N
= 516), separately, approximately 60% had CVD risk factor control. Overall, more fragmented care was not associated with worse control. However, among cancer survivors with excellent, very good, or good health, more fragmentation was associated with a decreased likelihood of diabetes control (OR 0.78, 95% CI 0.61–0.99), adjusting for confounders.
Conclusions
More fragmented care was associated with worse glycemic control among cancer survivors with diabetes who reported excellent, very good, or good health. Associations were not observed for control of hypertension or hyperlipidemia.
Implications for Cancer Survivors
Reducing fragmentation may support glucose control among survivors with diabetes.
More fragmented ambulatory care (i.e., care spread across many providers without a dominant provider) has been associated with more subsequent healthcare utilization (such as more tests, procedures, ...emergency department visits, and hospitalizations) than less fragmented ambulatory care. It is not known if race and socioeconomic status are associated with fragmented ambulatory care.
We conducted a longitudinal analysis of data from the REasons for Geographic and Racial Differences in Stroke (REGARDS) study, using the REGARDS baseline visit plus the first year of follow-up. We included participants ≥65 years old, who had linked fee-for-service Medicare claims, and ≥ 4 ambulatory visits in the first year of follow-up. We used Tobit regression to determine the associations between race, annual household income, and educational attainment at baseline and fragmentation score in the subsequent year (as measured with the reversed Bice-Boxerman Index). Covariates included other demographic characteristics, medical conditions, medication use, health behaviors, and psychosocial variables. Additional analyses categorized visits by the type of provider (primary care vs. specialist).
The study participants (N = 6799) had an average age of 73.0 years, 53% were female, and 30% were black. Nearly half had low annual household income (<$35,000) and 41% had a high school education or less. Overall, participants had a median of 10 ambulatory visits to 4 providers in the 12 months following their baseline study visit. Participants in the highest quintile of fragmentation scores had a median of 11 visits to 7 providers. Black race was associated with an absolute adjusted 3% lower fragmentation score compared to white race (95% confidence interval (2% lower to 4% lower; p < 0.001). This difference was explained by blacks seeing fewer specialists than whites. Income and education were not independent predictors of fragmentation scores.
Among Medicare beneficiaries, blacks had less fragmented ambulatory care than whites, due to lower utilization of specialty care. Future research is needed to determine the effect of fragmented care on health outcomes for blacks and whites.
Celotno besedilo
Dostopno za:
CEKLJ, DOBA, IZUM, KILJ, NUK, PILJ, PNG, SAZU, SIK, UILJ, UKNU, UL, UM, UPUK
During the height of the coronavirus (COVID-19) pandemic, there was an unprecedented demand for "virtual visits," or ambulatory visits conducted
video interface, in order to decrease the risk of ...transmission.
To describe the implementation and evaluation of a video visit program at a large, academic primary care practice in New York, NY, the epicenter of the COVID-19 pandemic.
We included consecutive adults (age > 18) scheduled for video visits from March 16, 2020 to April 17, 2020 for COVID-19 and non-COVID-19 related complaints.
New processes were established to prepare the practice and patients for video visits. Video visits were conducted by attendings, residents, and nurse practitioners.
Guided by the RE-AIM Framework, we evaluated the Reach, Effectiveness, Adoption, and Implementation of video visits.
In the 4 weeks prior to the study period, 12 video visits were completed. During the 5-weeks study period, we completed a total of 1,030 video visits for 817 unique patients. Of the video visits completed, 42% were for COVID-19 related symptoms, and the remainder were for other acute or chronic conditions. Video visits were completed more often among younger adults, women, and those with commercial insurance, compared to those who completed in-person visits pre-COVID (all
< 0.0001). Patients who completed video visits reported high satisfaction (mean 4.6 on a 5-point scale
: 0.97); 13.3% reported technical challenges during video visits.
Video visits are feasible for the delivery of primary care for patients during the COVID-19 pandemic.
Background More fragmented ambulatory care (ie, care spread across many providers without a dominant provider) has been associated with excess emergency department and inpatient care. We sought to ...determine whether more fragmented ambulatory care is associated with an increase in the hazard of incident stroke, overall and stratified by health status and by race. Methods and Results We conducted a secondary analysis of data from the REGARDS (Reasons for Geographic and Racial Differences in Stroke) study (2003-2016), including participants aged ≥65 years who had linked Medicare fee-for-service claims and no history of stroke (N=12 510). We measured fragmentation of care with the reversed Bice-Boxerman index. We used Poisson models to determine the association between fragmentation and adjudicated incident stroke. The average age of participants was 70.5 years; 53% were women, 32% were Black participants, and 16% were participants with fair or poor health. Overall, the adjusted rate of incident stroke was similar for high versus low fragmentation (8.2 versus 8.1 per 1000 person-years, respectively;
=0.89). Among participants with fair or poor self-rated health, having high versus low fragmentation was associated with a trend toward a higher adjusted rate of incident strokes (14.8 versus 10.4 per 1000 person-years, respectively;
=0.067). Among Black participants with fair or poor self-rated health, having high versus low fragmentation was associated with a higher adjusted rate of strokes (19.3 versus 10.3 per 1000 person-years, respectively;
=0.02). Conclusions Highly fragmented ambulatory care is independently associated with incident stroke among Black individuals with fair or poor health.
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