Advanced liver fibrosis is an important predictor of liver disease progression and mortality, and current guidelines recommend screening for complications of cirrhosis once patients develop F3 ...fibrosis. Our study compared liver disease progression and survival in patients with stage 3 (F3) and stage 4 (F4) fibrosis on liver biopsy.
Retrospective study of patients with F3 or F4 on liver biopsy followed for development of liver disease complications (variceal bleeding, ascites, and hepatic encephalopathy); hepatocellular carcinoma, and survival (overall and transplant free survival).
Of 2488 patients receiving liver biopsy between 01/02 and 12/12, a total of 294 (171 F3) were analyzed. Over a median follow up period of 3 years, patients with F4 (mean age 53 years, 63% male) compared to F3 (mean age 49 years, 43% male) had higher five year cumulative probability of any decompensation (38% vs. 14%, p<0.0001), including variceal bleed (10% vs. 4%, p = 0.014), ascites (21% vs. 9%, p = 0.0014), and hepatic encephalopathy (14% vs. 5%, p = 0.003). F4 patients also had lower overall 5-year survival (80% vs. 93%, p = 0.003) and transplant free survival (80% vs. 93%, p = 0.002). Probability of hepatocellular carcinoma in 5 years after biopsy was similar between F3 and F4 (1.2% vs. 2%, p = 0.54).
Compared to F4 stage, patients with F3 fibrosis have decreased risk for development of liver disease complications and better survival. Prospective well designed studies are suggested with large sample size and overcoming the limitations identified in this study, to confirm and validate these findings, as basis for modifying guidelines and recommendations on follow up of patients with advanced fibrosis and stage 3 liver fibrosis.
Older adults with Alzheimer's disease and related dementias (ADRD) are high-risk to experience hospitalizations and emergency room (ER) admissions. Mexican-Americans have a high prevalence of ADRD, ...but there is limited information on the healthcare use of older Mexican-Americans with ADRD. We used data from a cohort of older Mexican-Americans that has been linked with Medicare files to investigate differences in hospitalizations, ER admissions, and physician visits according to ADRD diagnosis. We also identify sociodemographic, health, and functional characteristics that may contribute to differences in healthcare utilization between Mexican-American Medicare beneficiaries with and without an ADRD diagnosis.
Data came from the Hispanic Established Populations for the Epidemiological Study of the Elderly that has been linked with Medicare Master Beneficiary Summary Files, Medicare Provider Analysis and Review files, Outpatient Standard Analytic files, and Carrier files. The final analytic sample included 1048 participants. Participants were followed for two years (eight quarters) after their survey interview. Generalized estimating equations were used to estimate the probability for one or more hospitalizations, ER admissions, and physician visits at each quarter. ADRD was associated with higher odds for hospitalizations (OR = 1.65, 95%CI = 1.29-2.11) and ER admissions (OR = 1.57, 95%CI = 1.23-1.94) but not physician visits (OR = 1.23, 95%CI = 0.91-1.67). The odds for hospitalizations (OR = 1.24, 95%CI = 0.97-1.60) and ER admissions (OR = 1.27, 95%CI = 1.01-1.59) were reduced after controlling for limitations in activities of daily living and comorbidities.
Mexican-American Medicare beneficiaries with ADRD had significantly higher odds for one or more hospitalizations and ER admissions but similar physician visits compared to beneficiaries without ADRD. Functional limitations and comorbidities contributed to the higher hospitalizations and ER admissions for older Mexican-Americans with ADRD.
Studying team-based primary care using 100% national outpatient Medicare data is not feasible, due to limitations in the availability of this dataset to researchers.
We assessed whether analyses ...using different sets of Medicare data can produce results similar to those from analyses using 100% data from an entire state, in identifying primary care teams through social network analysis. First, we used data from 100% Medicare beneficiaries, restricted to those within a primary care services area (PCSA), to identify primary care teams. Second, we used data from a 20% sample of Medicare beneficiaries and defined shared care by 2 providers using 2 different cutoffs for the minimum required number of shared patients, to identify primary care teams.
The team practices identified with social network analysis using the 20% sample and a cutoff of 6 patients shared between 2 primary care providers had good agreement with team practices identified using statewide data (F measure: 90.9%). Use of 100% data within a small area geographic boundary, such as PCSAs, had an F measure of 83.4%. The percent of practices identified from these datasets that coincided with practices identified from statewide data were 86% versus 100%, respectively.
Depending on specific study purposes, researchers could use either 100% data from Medicare beneficiaries in randomly selected PCSAs, or data from a 20% national sample of Medicare beneficiaries to study team-based primary care in the United States.
The working schedules of hospitalists vary widely. Discontinuous schedules, such as 24 hours on and 48 hours off, result in several hospitalists providing care during a patient's hospital stay. Poor ...continuity of care during hospitalization may be associated with poor patient outcomes.
To determine whether admitted patients receiving care from hospitalists with more discontinuous schedules experience worse outcomes.
This retrospective cohort study used conditional models to assess Medicare claims data for 114 777 medical admissions of patients with a 3-day to 6-day length of stay from January 1, 2014, through November 30, 2016, who received all general medical care from hospitalists in 229 hospitals in Texas. Data were analyzed from November 2018 to June 2019.
For each admission, the weighted mean of schedule continuity for the treating hospitalists, assessed as the percentage of all their working days in that year that were part of a block of 7 or more consecutive working days, was calculated.
The primary outcome was patient mortality in the 30 days after discharge. Secondary outcomes were readmission rates and Medicare costs in the 30 days after discharge, and discharge destination.
Of the 114 777 patient admissions, the mean (SD) age was 79.9 (8.3) years, and 70 047 (61.0%) were women. For admissions in the lowest quartile for continuity of hospitalist schedules, the hospitalists providing care worked 0% to 30% of their total working days as part of a block of 7 or more consecutive days vs 67% to 100% for hospitalists providing care for patients in the highest quartile for continuity. Patient characteristics were not associated with the continuity of working schedules for the hospitalist(s) providing care. In conditional logistic regression models, admitted patients cared for by hospitalists in the highest quartile of schedule continuity (vs the lowest quartile) had lower 30-day mortality after discharge (adjusted odds ratio aOR, 0.88; 95% CI, 0.81-0.95), lower readmission rates (aOR, 0.94; 95% CI, 0.90-0.99), higher rates of discharge to the home (aOR, 1.08; 95% CI, 1.03-1.13), and lower 30-day postdischarge costs (-$223; 95% CI, -$441 to -$7). The results were similar across a range of different methods for defining continuity of hospitalist schedules and selecting the cohort.
Hospitalist schedules vary widely. Admitted patients receiving care from hospitalists with schedules that promote inpatient continuity of care may experience better outcomes of hospitalization.
ABSTRACT
BACKGROUND
Diagnostic imaging is not recommended in the evaluation and management of non-specific acute low back pain.
OBJECTIVE
To estimate the variation among primary care providers (PCPs) ...in the use of diagnostic imaging for older patients with non-specific acute low back pain.
DESIGN AND PARTICIPANTS
Retrospective cohort study using 100 % Texas Medicare claims data. We identified 145,320 patients aged 66 years and older with non-specific acute low back pain during the period January 1, 2007, through November 30, 2011, cared for by 3297 PCPs.
MAIN MEASURES
We tracked whether each patient received lumbar imaging (radiography, computed tomography CT, or magnetic resonance imaging MRI) within 4 weeks of the initial visit. Multilevel logistic regression models were used to estimate physician-level variation in imaging use.
KEY RESULTS
Among patients, 27.2 % received radiography and 11.1 % received CT or MRI within 4 weeks of the initial visit for low back pain. PCPs varied substantially in the use of imaging. The average rate of radiography within 4 weeks was 53.9 % for PCPs in the highest decile, compared to 6.1 % for PCPs in the lowest decile. The average rates of CT/MRI within 4 weeks were 18.5 % vs. 3.2 % for PCPs in the highest and lowest deciles, respectively. The specific physician seen by a patient accounted for 25 % of the variability in whether imaging was performed, while only 0.44 % of the variance was due to measured patient characteristics and 1.4 % to known physician characteristics. Use of imaging by individual physicians was stable over time.
CONCLUSIONS
PCPs vary substantially in the use of imaging for non-specific acute low back pain. Provider-level measures can be employed to provide feedback to physicians in an effort to modify imaging use.
Abstract Background There is growing concern about potential overuse of, and toxicity from, opioid analgesics. No nationally representative study has examined inter-state variations in opioid use and ...impact of policy on opioid use among older adults. Methods We used national Medicare data from 2007-2012 to assess temporal and geographic trends in rates of opioid prescription and relationship to opioid toxicity and different state regulations in Part D Medicare recipients. We excluded those with a cancer diagnosis. Multilevel, multivariable regression analyses evaluated rates of prolonged prescriptions for schedule II, schedule III, and combination II/III opioid for each state, adjusting for patient characteristics. Results The percent of Part D recipients receiving prescriptions for combined schedule II/III opioid more than 90 days in a year increased from 4.62% in 2007 to 7.35% in 2012. Large variations existed among states in rates of opioid prescriptions: from 2.84% in New York to 10.93% in Utah, in 2012 data. The state variation was larger for schedule III than schedule II. Individual characteristics independently associated with prolonged use included older age, female gender, white race, low income, living in a lower-education area, and comorbidity of drug abuse, rheumatoid arthritis, and depression. Only state law regulating pain clinic was associated with reduction of schedule II opioid prescriptions. Prolonged opioid prescription use increased the odds of opioid overdose-related emergency room visits or hospitalization by 60%. Conclusions Analyses of Medicare Part D data demonstrated a substantial growth in opioid prescriptions from 2007 to 2011 and large variation in opioid prescriptions across states.
The association between smoking status and severe Coronavirus Disease 2019 (COVID-19) remains controversial.
To assess the risk of hospitalization (as a marker of severe COVID-19) in patients by ...smoking status: former, current and never smokers, who tested positive for the Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-COV2) at an academic medical center in the United States.
We conducted a retrospective cohort study in patients with SARS-COV2 between March-1-2020 and January-31-2021 to identify the risk of hospitalization due to COVID-19 by smoking status.
We identified 10216 SARS-COV2-positive patients with complete documentation of smoking habits. Within 14 days of a SARS-COV2 positive test, 1150 (11.2%) patients were admitted and 188 (1.8%) died. Significantly more former smokers were hospitalized from COVID-19 than current or never smokers (21.2% former smokers; 7.3% current smokers; 10.4% never smokers, p<0.0001). In univariable analysis, former smokers had higher odds of hospitalization from COVID-19 than never smokers (OR 2.31; 95% CI 1.94-2.74). This association remained significant when analysis was adjusted for age, race and gender (OR 1.28; 95% CI 1.06-1.55), but became non-significant when analysis included Body Mass Index, previous hospitalization and number of comorbidities (OR 1.05; 95% CI 0.86-1.29). In contrast, current smokers were less likely than never smokers to be hospitalized due to COVID-19.
Significantly more former smokers were hospitalized and died from COVID-19 than current or never smokers. This effect is mediated via age and comorbidities in former smokers.
•Former smokers are at higher risk for hospitalization and death from COVID-19 than current or never smokers.•Increase risk of hospitalizations seen among former smokers is mediated through older age and higher comorbidities burden.•Odds of hospitalization from COVID-19 increased by 6% for every year of age in the population studied after adjusting for other covariates.
Gabapentinoids (GABAs) and serotonergic drugs (selective serotonin reuptake inhibitors SSRIs/serotonin and norepinephrine reuptake inhibitors SNRIs) are increasingly being prescribed as potential ...substitutes to opioids and benzodiazepines (benzos), respectively, to treat co-occurring pain and anxiety disorders. The toxicities of these drug classes and their combinations are not well understood.
We conducted a matched case-control study using 2013-2016 Medicare files linked to the National Death Index. Cases were enrollees who died from drug overdose. Controls were enrollees who died from other causes. Cases and controls were matched on patient characteristics and prior chronic conditions. Possession of any opioids, GABAs, benzos, and SSRIs/SNRIs in the month prior to death was defined as drug use. Combination drug use was defined as possessing at least 2 types of these prescriptions for an overlapping period of at least 7 days in the month prior to death.
Among 4323 matches, benzo possession was associated with twice the risk for drug overdose death in cases vs controls. Compared with opioid-benzo co-prescribing, combinations involving SSRIs/SNRIs and opioids (or GABAs) were associated with decreased risk (adjusted odds ratio 0.55; 95% confidence interval, 0.44-0.69 for opioids and SSRIs/SNRIs; adjusted odds ratio 0.59; 95% confidence interval, 0.44-0.79 for GABAs and SSRIs/SNRIs). Fatal drug overdose risk was similar in users of GABA-opioid, GABA-benzo, and opioid-benzo combinations.
Benzodiazepines, prescribed alone or in combination, were associated with an increased risk of drug overdose death. SSRIs/SNRIs were associated with lower risk of overdose death vs benzodiazepines. GABAs were not associated with decreased risk compared with opioids, raising concerns for GABAs’ perceived relative safety.
Team care improves processes and outcomes of care, especially for patients with complex medical conditions that require coordination of care. This study aimed to compare the processes and outcomes of ...care provided to older patients with diabetes by primary care teams comprised of only primary care physicians (PCPs) versus team care that included nurse practitioners (NPs) or physician assistants (PAs).
We studied 3,524 primary care practices identified via social network analysis and 306,741 patients ≥66 years old diagnosed with diabetes in or before 2015 in Medicare data. Guideline-recommended diabetes care included eye examination, hemoglobin A1c test, and nephropathy monitoring. High-risk medications were based on recommendations from the American Geriatrics Society Beers Criteria for Potentially Inappropriate Medication Use in Older Adults. Preventable hospitalizations were defined as hospitalizations for a potentially preventable condition.
Compared with patients in the PCP only teams, patients in the team care practices with NPs or PAs received more guideline-recommended diabetes care (annual eye exam: adjusted odds ratio (aOR): 1.04 (95% CI: 1.00-1.08), 1.08 (95% CI: 1.03-1.13), and 1.10 (95% CI: 1.05-1.15), and HbA1C test: aOR: 1.11 (95% CI: 1.04-1.18), 1.11 (95% CI: 1.02-1.20), and 1.15 (95% CI: 1.06-1.25) for PCP/NP, PCP/NP/PA, and PCP/PA teams). Patients in the PCP/NP and the PCP/PA teams had a slightly higher likelihood of being prescribed high-risk medications (aOR: 1.03 (95% CI: 1.00-1.07), and 1.06 (95% CI: 1.02-1.11), respectively). The likelihood of preventable hospitalizations was similar among patients cared for by various types of practices.
The team care practices with NPs or PAs were associated with better adherence to clinical practice guideline recommendations for diabetes compared to PCP only practices. Both practices had similar outcomes. Further efforts are needed to explore new and cost-effective team-based care delivery models that improve process, outcomes, and continuity of care, as well as patient care experiences.
ObjectiveExamine the association between the co-prescribing of opioids, benzodiazepines, gabapentinoids (pregabalin and gabapentin) and selective serotonin reuptake inhibitors/serotonin and ...norepinephrine reuptake inhibitors (SSRI/SNRIs) in different combinations and the risk of falls and fractures.DesignRetrospective cohort study from 2015 to 2018.SettingMedicare enrolment and claims data.ParticipantsMedicare beneficiaries with both chronic pain and anxiety disorders in 2016 with continuous enrolments in Parts A and B from 2015 to 2016 who were prescribed any combination of opioid, benzodiazepine, gabapentinoid and SSRI/SNRI in 2017 for ≥7 days, as documented in their Medicare Part D coverage.InterventionsAny combination of use of seven drug regimens (benzodiazepine +opioid; benzodiazepine +gabapentinoid; benzodiazepine +SSRI/SNRI; opioid +gabapentinoid; opioid +SSRI/SNRI; gabapentinoid +SSRI/SNRI; ≥3 drug classes).Main outcomesFirst event of fall and the first event of fracture after the index date, which was the first day of combination drug use that lasted ≥7 days in 2017.ResultsA total of 47 964 patients (mean SD age, 75.9 7.1; 78.0% woman) with diagnoses of both chronic pain and anxiety were studied. The median (Q1–Q3) duration of drug combination use was 26 (14-30) days. After adjusting for demographic characteristics, chronic conditions and history of hospitalisation and fall or fracture, the co-prescribing of ≥3 drugs (adjusted HR aHR, 1.38; 95% CI 1.14 to 1.67) and opioid plus gabapentinoid (aHR, 1.18; 95% CI 1.02 to 1.37) were associated with a high fall risk, compared with benzodiazepineplus opioid co-prescribing, findings consistent with the secondary analysis using inverse probability of treatment weighting with propensity scores. The co-prescribing of benzodiazepine plus gabapentinoid (aHR, 0.76; 95% CI 0.59 to 0.98) was associated with lower fracture risk compared with the co-prescribing of benzodiazepine plus opioid, though this finding was not robust.ConclusionsOur findings add to comparative toxicity research on different combinations of gabapentinoids and serotonergic agents commonly prescribed with or as substitutes for opioids and benzodiazepines in patients with co-occurring chronic pain and anxiety.
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