Objectives
To determine how the risk of subsequent long‐term care (LTC) placement varies between skilled nursing facilities (SNFs) and the SNF characteristics associated with this risk.
Design
...Population‐based national cohort study with participants nested in SNFs and hospitals in a cross‐classified multilevel model.
Setting
SNFs (N=6,680).
Participants
Fee‐for‐service Medicare beneficiaries (N=552,414) discharged from a hospital to a SNF in 2013.
Measurements
Participant characteristics from Medicare data and the Minimum Data Set. SNF characteristics from Medicare and Nursing Home Compare. Outcome was a stay of 90 days or longer in a LTC nursing home within 6 months of SNF admission.
Results
Within 6 months of SNF admission, 10.4% of participants resided in LTC. After adjustments for participant characteristics, the SNF where a participant received care explained 7.9% of the variance in risk of LTC, whereas the prior hospital explained 1.0%. Individuals in SNFs with excellent quality ratings had 22% lower odds of transitioning to LTC than those in SNFs with poor ratings (odds ratio=0.78, 95% confidence interval=0.74–0.84). Variation between SNFs and associations with quality markers were greater in sensitivity analyses limited to individuals least likely to require LTC. Results were essentially the same in a number of other sensitivity analyses designed to reduce potential confounding.
Conclusion
Risk of subsequent LTC placement, an important and negatively viewed outcome for older adults, varies substantially between SNFs. Individuals in higher‐quality SNFs are at lower risk.
See related editorial by Vincent Mor et al.
ObjectiveOpioid and benzodiazepine co-prescribing is associated with a substantial increase in opioid overdose deaths. In this study, we examine the prescribing trends of substitutes of opioids and ...benzodiazepines alone or in combination, compared with opioids and benzodiazepines.DesignRetrospective cohort study.SettingData were collected using a 20% national sample of Medicare beneficiaries from 2013 to 2018.Participants4.1–4.3 million enrollees each year from 2013 to 2018.InterventionNone.Primary outcomeWe employ a generalised linear mixed models to calculate ORs for opioid use, benzodiazepine or Z-drug (benzos/Z-drugs) use, opioid/benzos/Z-drugs 30-day use, gabapentinoid use and (selective serotonin reuptake inhibitors (SSRI) and serotonin norepinephrine reuptake inhibitors (SNRIs)) use, adjusted for the repeated measure of patient. We then created two models to calculate the ORs for each year and comparing to 2013.ResultsOpioid and benzos/Z-drugs use decreased by 2018 (aOR 0.626; 95% CI 0.622 to 0.630) comparing to 2013. We demonstrate a 36.3% and 9.9% increase rate of gabapentinoid and SSRI/SNRI use, respectively. Furthermore, combined gabapentinoid and SSRI/SNRI use increased in 2018 (aOR 1.422; 95% CI 1.412 to 1.431).ConclusionLittle is known about the prescribing pattern and trend of opioid and benzodiazepine alternatives as analgesics. There is a modest shift from prescribing opioid and benzos/Z-drugs (alone or in combination) towards prescribing non-opioid analgesics—gabapentinoids with and without non-benzos/Z-drugs that are indicated for anxiety. It is unclear if this trend towards opioid/benzos/Z-drugs alternatives is associated with fewer drug overdose death, better control of pain and comorbid anxiety, and improved quality of life.
A population-based retrospective cohort study.
The aim of this study was to examine risk factors for long-term opioid use following lumbar spinal fusion surgery in a nationally representative cohort ...of commercially insured adults.
Opioid prescription rates for the management of low back pain have more than doubled in the US over the past decade. Although opioids are commonly used for the management of pain following lumbar spinal fusion surgery, to date, no large-scale nationally representative studies have examined the risk factors for long-term opioid use following such surgical intervention.
Using one of the nation's largest commercial insurance databases, we conducted a retrospective cohort study of 8377 adults, aged 21 to 63 years, who underwent lumbar spinal fusion surgery between January 1, 2009, and December 31, 2012. Long-term opioid use was defined as ≥365 days of filled opioid prescriptions in the 24 months following lumbar fusion. Multivariable logistic regression was used to calculate adjusted odds ratios (ORs) and 95% confidence intervals for the risk of long-term opioid use following lumbar fusion.
After adjusting for covariates, the following factors were associated with an increased risk of long-term opioid use following surgery: duration of opioid use in the year before lumbar surgery Referent (0 days); Quartile 1 (1-22 days) OR = 2.27, 95% CI = 1.48-3.49; Quartile 2 (23-72 days): OR = 5.94, 95% CI = 4.00-8.83; Quartile 3: (73-250 days) OR = 25.31, 95% CI = 17.26-37.10; Quartile 4 (≥250 days) OR = 219.95, 95% CI = 148.53-325.71), refusion surgery (OR = 1.32, 95% CI = 1.02-1.72), and diagnosis of depression (OR = 1.43, 95% CI = 1.18-1.74). Receipt of anterior fusion was associated with a modest decrease in the risk of long-term opioid use (OR = 0.79, 95% CI = 0.63-0.99).
These findings may provide clinically relevant information to physicians, patients, and their families regarding the risk factors for opioid dependence following lumbar fusion surgery.
3.
Background
The independent and joint association of metformin and testosterone replacement therapy (TTh) with the incidence of prostate, colorectal, and male breast cancers remain poorly understood, ...including the investigation of the risk of these cancers combined (HRCs, hormone‐associated cancers) among men of different racial and ethnic background.
Methods
In 143,035 men (≥ 65 yrs old) of SEER‐Medicare 2007–2015, we identified White (N = 110,430), Black (N = 13,520) and Other Race (N = 19,085) men diagnosed with incident HRC. Pre‐diagnostic prescription of metformin and TTh was ascertained for this analysis. Weighted multivariable‐adjusted conditional logistic and Cox proportional hazards models were conducted.
Results
We found independent and joint associations of metformin and TTh with incident prostate (odds ratio ORjoint = 0.44, 95% confidence interval CI: 0.36–0.54) and colorectal cancers (ORjoint = 0.47, 95% CI: 0.34–0.64), but not with male breast cancer. There were also inversed joint associations of metformin and TTh with HRCs (ORjoint = 0.45, 95% CI: 0.38–0.54). Similar reduced associations with HRCs were identified among White, Black, and Other Race men.
Conclusion
Pre‐diagnostic use of metformin and TTh were, independently and jointly, inversely associated with incident prostate and colorectal cancers. The risk of HRCs was also reduced among White, Black and Other Race men. Greatest reduced associations of prostate and colorectal cancers and HRCs were mainly observed in combination of metformin and TTh. Larger studies are needed to confirm the independent and joint association of metformin plus TTh with these cancers in understudied and underserved populations.
Use of BRCA Mutation Test in the U.S., 2004–2014 Guo, Fangjian, MD, PhD; Hirth, Jacqueline M., PhD, MPH; Lin, Yu-li, MS ...
American journal of preventive medicine,
06/2017, Letnik:
52, Številka:
6
Journal Article
Recenzirano
Odprti dostop
Introduction BRCA mutation testing has been used for screening women at high risk of breast and ovarian cancer and for selecting the best treatment for those with breast cancer. To optimize the ...infrastructure and medical resources allocation for genetic testing, it is important to understand the use of BRCA mutation testing in the U.S. health system. Methods This retrospective cohort study included 53,254 adult women with insurance claims for BRCA mutation testing between 2004 and 2014 from ClinformaticsTM Data Mart Database. Data analysis was performed in 2016. This study assessed trends in the use of BRCA mutation testing in women with previously diagnosed breast or ovarian cancer and those without (unaffected women). Results Between 2004 and 2014, of those receiving BRCA testing, the proportion of BRCA tests performed in unaffected women increased significantly ( p <0.001), from 24.3% in 2004 to 61.5% in 2014. An increase in the proportion of BRCA tests used in unaffected women was found in each characteristic subgroup. In 2014, most subgroups had a proportion surpassing 50%, except for those aged 51–65 years and those without a family history of breast cancer. There was a much lower proportion of those aged 20–40 years among tested women with previously diagnosed breast or ovarian cancer than in unaffected women (17.6% vs 41.7%, p <0.001). Conclusions During the past decade, the role of BRCA testing has gradually shifted from being used primarily in cancer patients to being used in unaffected women in the U.S.
Alcohol-associated liver disease is increasing, especially hospitalizations with acute on chronic liver failure and need for liver transplant. We examined trends in prevalence, inhospital mortality, ...and resource utilization associated with AALD and ACLF in the young.
The National Inpatient Sample (2006-2014) was queried for hospitalizations with a discharge diagnosis of cirrhosis using the International Classification of Diseases, Ninth Edition, codes. ACLF hospitalization was defined as ≥2 organ failures and stratified by age: young (≤35 years) and older (>35 years).
Of 447,090 AALD admissions (16,126 in young) between 2006 and 2014, ACLF occurred in 29,599 (6.6%), of which 1,143 (7.1%) were in young. Compared with older, admissions in young had more women (35% vs 29%), were obese (11% vs 7.6%), were Hispanics (29% vs 18%), have alcoholic hepatitis (AH) (41% vs 17%), and have ACLF grades 2 or 3 (34% vs 25%), P < 0.001 for all. Between 2006 and 2014, ACLF in AALD among young increased from 2.8% to 5.2%, with an AH proportion from 24% to 42%, P < 0.0001 for both. Young had more complications requiring ventilation (79% vs 76%) and dialysis (32% vs 28%), P < 0.001 for both. Compared with older, ACLF admission in young had longer hospitalization (12 vs 10 days) with higher hospital charges ($127,915 vs $97,511), P < 0.0001 for both, with 20% reduced inhospital mortality (54%-45%), P < 0.001.
AALD-related hospitalizations are increasing in young in the United States, mainly because of the increasing frequency of AH. Furthermore, this disease burden in young is increasing with a higher frequency of admissions with more severe ACLF and consumption of hospital resources. Studies are needed to develop preventive strategies to reduce burden related to AALD and ACLF in young.
BACKGROUND/OBJECTIVES
Peripheral neuropathy is a common diabetes complication that can increase fall risk. Regarding fall risk, the impact of pain management using tricyclic antidepressants (TCAs) or ...γ‐aminobutyric acid (GABA) analogs is unclear because these medications can also cause falls. This study investigates the impact of these drugs on fall and fracture risk in older diabetic peripheral neuropathy (DPN) patients.
DESIGN
Historical cohort study with 1‐to‐1 propensity matching of TCA/GABA‐analog users and nonusers.
SETTING
Nationally representative 5% Medicare sample between the years 2008 and 2010.
PARTICIPANTS
After applying all selection criteria, 5,550 patients with prescription and 22,200 patients without prescription of TCAs/GABA‐analogs were identified. Both patient groups were then stratified for fall history and matched based on propensity of receiving TCAs/GABA‐analogs within each group.
MEASUREMENTS
Patients were followed until the first incidence of fall or the first incidence of fracture during the follow‐up period (for up to 5 years).
RESULTS
After matching, users and nonusers were largely similar. After covariate adjustment, TCA/GABA‐analog use was associated with a statistically significant increase in fall risk (adjusted hazard ratio HR = 1.11; 95% confidence interval CI = 1.03‐1.20), but was not associated with fracture risk (adjusted HR = 1.09; 95% CI = 0.99‐1.19) in the conventional analysis. Treating TCA/GABA‐analog use as a time‐dependent covariate resulted in statistically significant associations of TCA/GABA‐analog use with both fall and fracture risk (HR = 1.26 95% CI = 1.17‐1.36; and HR = 1.12 95% CI = 1.02‐1.24, respectively).
CONCLUSION
Among older patients with DPN, GABA‐analogs or TCAs increase fall risk and possibly fracture risk. Use of these medications is therefore a potentially modifiable risk factor for falls and fractures in this population.
Background
Prescription opioid overprescribing is a focal point for legislators, but little is known about opioid prescribing patterns of primary care nurse practitioners (NPs) and physician ...assistants (PAs).
Objective
To identify prescription opioid overprescribers by comparing prescribing patterns of primary care physicians (MDs), nurse practitioners (NPs), and physician assistants (PAs).
Design
Retrospective, cross-sectional analysis of Medicare Part D enrollee prescription data.
Participants
Twenty percent national sample of 2015 Medicare Part D enrollees.
Main Measures
We identified potential opioid overprescribing as providers who met at least one of the following: (1) prescribed any opioid to > 50% of patients, (2) prescribed ≥ 100 morphine milligram equivalents (MME)/day to > 10% of patients, or (3) prescribed an opioid > 90 days to > 20% of patients.
Key Results
Among 222,689 primary care providers, 3.8% of MDs, 8.0% of NPs, and 9.8% of PAs met at least one definition of overprescribing. 1.3% of MDs, 6.3% of NPs, and 8.8% of PAs prescribed an opioid to at least 50% of patients. NPs/PAs practicing in states with independent prescription authority were > 20 times more likely to overprescribe opioids than NPs/PAs in prescription-restricted states.
Conclusions
Most NPs/PAs prescribed opioids in a pattern similar to MDs, but NPs/PAs had more outliers who prescribed high-frequency, high-dose opioids than did MDs. Efforts to reduce opioid overprescribing should include targeted provider education, risk stratification, and state legislation.
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