Background
Human papillomavirus (HPV)–related disease remains a significant source of morbidity and mortality, and this underscores the need to increase HPV vaccination to reduce the burden of the ...disease. The objective of this study was to examine the association between the number of HPV vaccine doses and the risk of histologically confirmed preinvasive cervical disease and high‐grade cytology.
Methods
This retrospective matched cohort study used administrative data from Optum's Clinformatics DataMart Database to identify females aged 9 to 26 years who received 1 or more quadrivalent HPV vaccine doses between January 2006 and June 2015. Cases and controls were matched on region, age, sexually transmitted disease history, and pregnancy. All had a Papanicolaou test ≥1 year after the date of the matched case's final dose. Cox proportional hazards models were used to examine the association between the number of HPV vaccine doses and the incidence of preinvasive cervical disease and high‐grade cytology. The Kaplan‐Meier method was used to estimate the cumulative incidence rate at the 5‐year follow‐up.
Results
The study included 133,082 females (66,541 vaccinated and 66,541 unvaccinated) stratified by the number of HPV vaccine doses and the vaccine initiation age. Among those aged 15 to 19 years, the hazard ratio (HR) for high‐grade cytology for the 3‐dose group was 0.84 (95% confidence interval CI, 0.73‐0.97), whereas the HRs for histologically confirmed preinvasive cervical disease for 1, 2, and 3 doses were 0.64 (95% CI, 0.47‐0.88), 0.72 (95% CI, 0.54‐0.95), and 0.66 (95% CI, 0.55‐0.80), respectively.
Conclusions
The receipt of 1, 2, or 3 doses of an HPV vaccine by females aged 15 to 19 years was associated with a lower incidence of preinvasive cervical disease in comparison with unvaccinated females, and this supports the use of any HPV vaccination in reducing the burden of the disease.
This study examines the association between varying numbers of human papillomavirus vaccine doses and the risk of cervical intraepithelial neoplasia II/III and atypical squamous cells (which cannot exclude a high‐grade squamous intraepithelial lesion)/high‐grade squamous intraepithelial lesions. The receipt of 1, 2, or 3 human papillomavirus vaccine doses between the ages of 15 and 19 years is associated with a lower risk of cervical intraepithelial neoplasia II/III.
OBJECTIVES
To examine the rates and predictors of long‐term opioid therapy in older cancer survivors.
DESIGN
Retrospective cohort study.
SETTING
Texas, United States.
PARTICIPANTS
Cancer survivors (5 ...years or more postcancer diagnosis) diagnosed from 1995 to 2008 and who were also Medicare Parts A, B, and D beneficiaries.
MEASUREMENTS
We used Medicare Part D event data to calculate the proportion of cancer survivors with a prolonged opioid prescription (90‐day or more supply of opioids/year). Adjusted odds ratios were calculated to identify predictors of prolonged opioid prescribing. All analyses were repeated with a subcohort of opioid‐naïve cancer survivors.
RESULTS
The rate of prolonged opioid therapy for cancer patients diagnosed in 2008 was 7.1% prior to cancer diagnosis; it rose to 9.8% within a year of cancer treatments, and to 13.3% at 5 years postdiagnosis. The rate at the sixth year varied by cancer sites: 19.4% in lung cancer and 9.6% in prostate cancer. Among opioid‐naïve survivors, the rate increased from 1.4% to 7.1%, from 5 to 18 years postcancer diagnosis. Cancer survivors diagnosed in 2004 to 2008 had higher rates of opioid prescribing compared to those diagnosed in 1995 to 1998 and 1999 to 2003. Years since diagnosis, a later year of diagnosis, female sex, urban location, lung cancer diagnosis, disability as reason for Medicare entitlement, Medicaid eligibility, one or more comorbidity, and history of depression or drug abuse were predictors of prolonged opioid therapy. Among opioid‐naïve cancer survivors, diagnosis in 2004 to 2008 was the strongest predictor, while a history of drug abuse was the strongest predictor for all the survivors.
CONCLUSION
The rates of prolonged opioid prescribing for older cancer survivors remained high at 5 or more years after cancer diagnosis. Our findings have potential to inform the development of clinical guidelines and public policy to ensure safer and more effective pain treatment in older cancer survivors. J Am Geriatr Soc 67:945–952, 2019.
An increasing number of older adults with traumatic brain injury (TBI) require hospitalization, but it is unknown whether they return to their community following discharge. We examined community ...residence following acute hospital discharge for TBI in Texas and identified factors associated with 90-day community residence and readmission.
We conducted a retrospective cohort study using 100% Texas Medicare claims data of patients older than 65 years hospitalized for a TBI from January 1, 2014, through December 31, 2017, and followed for 20 weeks after discharge. Discharges to short-term and long-term acute hospital, inpatient rehabilitation facility (IRF), skilled nursing facility (SNF), long-term nursing home (NH), and hospice were identified. The primary outcome was 90-day community residence. Our secondary outcome was 90-day, all-cause readmission.
In Texas, 26,985 Medicare fee-for-service patients were hospitalized for TBI (Racial and ethnic minorities: 21.1%; Females 57.3%). At 90 days and 20 weeks following discharge, 80% and 84% were living in the community respectively. Female sex (OR = 1.16 1.08-1.25), Hispanic ethnicity (OR = 2.01 1.80-2.25), "other" race (OR = 2.19 1.73-2.77), and prior primary care provider (PCP; OR = 1.51 1.40-1.62) were associated with increased likelihood of 90-day community residence. Patients aged 75+, prior NH residence, dual eligibility, prior TBI diagnosis, and moderate-to-severe injury severity were associated with decreased likelihood of 90-day community residence. Being non-Hispanic Black (HR = 1.33 1.20-1.46), discharge to SNF (HR = 1.56 1.48-1.65) or IRF (HR = 1.49 1.40-1.59), having prior PCP (HR = 1.23 1.17-1.30), dual eligibility (HR = 1.11 1.04-1.18), and prior TBI diagnosis (HR = 1.05 1.01-1.10) were associated with increased risk of 90-day readmission. Female sex and "other" race were associated with decreased risk of 90-day readmission.
Most older adults with TBI return to the community following hospital discharge. Disparities exist in returning to the community and in risk of 90-day readmission following hospital discharge. Future studies should explore how having a PCP influences post-hospital outcomes in chronic care management of older patients with TBI.
Background/Objectives
Approximately half of individuals newly admitted to long‐term care (LTC) nursing homes (NHs) experienced a prior hospitalization followed by discharge to a skilled nursing ...facility (SNF). The objective was to examine characteristics associated with new institutionalizations of older adults on this care trajectory.
Design
Retrospective cohort study.
Setting
SNFs and LTC NHs.
Patients
Medicare fee‐for‐service beneficiaries admitted to 7,442 SNFs in 2013 (N = 597,986).
Measurements
We used demographic and clinical characteristics from Medicare data and the Minimum Data Set. We defined “new institutionalization” as LTC NH residence for longer than 90 non‐SNF days, starting within 6 months of hospital discharge.
Results
For individuals who survived 6 months after hospital discharge, the overall rate of new LTC institutionalizations was 10.0% (N = 59,736). Older age, white race, being unmarried, Medicaid eligibility, higher income, more comorbidities, cognitive impairment, depression, functional limitations, hallucinations and delusions, aggressive behavior, incontinence, and pressure ulcers were associated with higher adjusted odds of new LTC institutionalization. In analyses stratified according to race and ethnicity, higher income was associated with lower odds of LTC institutionalization for whites (odds ratio (OR) = 0.92, 95% confidence interval (CI) = 0.89–0.96) and greater odds for blacks (OR = 1.40, 95% CI = 1.27–1.55) and Hispanics (OR = 1.44, 95% CI = 1.25–1.66). Moderate or severe depression, functional limitations, hallucinations and delusions, aggressive behavior, and being unmarried were stronger risk factors for LTC for cognitively intact individuals than for those with moderate to severe cognitive impairment. Being unmarried and having more comorbidities were stronger predictors in those aged 66 to 70 than in those aged 81 to 85 and 91 and older.
Conclusion
Associations between risk factors and new LTC institutionalizations varied according to race and ethnicity, age, and level of cognitive function. Programs that target older adults at greater risk may be an effective strategy for reducing new institutionalizations and fostering aging in place.
Background/Objective
To assess the impact of team structure composition and degree of collaboration among various providers on process and outcomes of primary care.
Design
Cross‐sectional study.
...Setting
Data from 20% randomly selected primary care service areas in the 2015 Medicare claims was used to identified primary care practices.
Participants
449,460 patients with diabetes, heart failure, or chronic obstructive pulmonary disease cared for by the identified primary care practices.
Measurements
SNA network measures, including edge density, degree centralization, and betweenness centralization for each practice.
Results
When compared to practices with MDs and nurse practitioners (NPs) or/and physicians assistants (PAs), the practices with MDs only had lower degree of centralization and higher MD‐to‐MD connectedness. Within the primary care practices comprising MDs, NPs or/and PAs, the non‐physician providers were more connected (measured as edge density) to all providers in the practice but with higher degree of centralization compared to the MDs in the practice. After adjusting for patient characteristics and type of practice, higher edge density was associated with lower odds of hospitalization (odds ratio OR: 0.89, 95% Confidence Interval CI: 0.79–0.99), emergency department (ER) admission (OR: 0.80, 95% CI: 0.70–0.92), and total spending (cost ratio CR: 0.86, standard error of the mean SE: 0.038). Conversely, higher degree centralization was associated with higher rates of hospitalization (OR: 1.15, 95% CI: 1.03–1.28), ER admission (OR: 1.23, 95% CI: 1.08–1.40), and total spending (CR: 1.14, SE: 0.037). However, higher degree centralization was associated with lower rates of potentially inappropriate medications (OR: 0.90, 95% CI: 0.81, 0.99). Team leadership by an NP versus an MD were similar in the rate of ER admissions, hospitalizations, or total spending.
Conclusion
Our findings showed that highly connected primary care practices with high collaborative care and less top‐down MD‐centered authority have lower odds of hospitalization, fewer ER admissions, and less total spending; findings likely reflecting better communication and more coordinated care of older patients.
Frequency of liver transplantation (LT) is increasing in nonalcoholic steatohepatitis (NASH) with good post-transplant outcomes. Similar data on simultaneous liver kidney (SLK) transplants are ...limited.
United Network for Organ Sharing database (2002-2011) queried for deceased donor first LT for primary biliary cirrhosis, primary sclerosing cholangitis, or alcoholic cirrhosis (group I), NASH, and cryptogenic cirrhosis with body mass index greater than 30 (group II), and hepatitis C virus with and without alcohol, hepatitis B virus, and hepatocellular carcinoma (group III).
Of 38 533 LT (9495, 3665, and 25 383 in groups I-III, respectively), about 5.6% (N = 2162) received SLK with 584 (6.2%), 320 (8.7%), and 1258 (5%) in groups I-III, respectively. The SLK performed for group II increased from 6.3% in 2002 to 2003 to 19.2% in 2010 to 2011. Similar trends remained unchanged in group I (26.1 to 26.6%) and decreased in group III (67.6 to 54.5%). Five-year outcomes were similar comparing group II versus group I for liver graft (78 vs 74%, P = 0.14) and patient survival (81 vs 76%, P = 0.07). In contrast, kidney graft outcome was worse for group II (70 vs 79%, P = 0.002). Risk of kidney graft loss was over 1.5-fold higher among group II SLK recipients compared to group I after controlling for recipient characteristics. Estimated glomerular filtration rate remained lower in group II compared with group I at various time points after SLK transplantation.
The NASH is the most rapidly growing indication for SLK transplantation with poor renal outcomes. Studies are needed to examine mechanisms of these findings and develop strategies to improve renal outcomes in SLK recipients for NASH.
Background
Invasive lobular carcinoma (ILC) is traditionally considered less responsive to chemotherapy. Although the Oncotype recurrence score (RS) has been validated to identify high‐risk patients ...who benefit from chemotherapy, some studies have questioned its relevance in patients with ILC. The objective of this study was to better characterize potential use of the RS in these patients.
Methods
The National Cancer Database was used to identify women with stage I through III, T1 through T3, N0 or N1, hormone receptor‐positive, HER2‐negative ILC or invasive ductal carcinoma (IDC) who had an available RS between 2010 and 2016. Multivariable Cox regression was used to model the effect of variables on 5‐year overall survival (OS). The Kaplan‐Meier method was used to estimate OS according to the RS, nodal status, and chemotherapy.
Results
In total, 15,763 patients with ILC and 100,070 with IDC were identified. The mean age of patients with ILC and IDC was 59.2 ± 9.1 and 57.2 ± 9.8, respectively. A lower percentage of patients with ILC versus those with IDC had a high RS, defined as >25 (6.6% vs 16.0%; P < .0001). ILC patients with a high RS who had N0 or N1 disease received approximately 10% less chemotherapy compared with similar patients who had IDC. The results indicated that the RS had statistically significant prognostic value for patients with ILC. In addition, an absolute OS advantage was correlated with the receipt of chemotherapy by patients with ILC who had a high RS with N0 or N1 disease.
Conclusions
Patients with ILC who have a high RS are treated less often with chemotherapy compared with similar patients who have IDC. Nevertheless, the RS has a prognostic as well as a predictive value in ILC, with an association between OS benefit and chemotherapy receipt in patients who have ILC with a high RS, especially if they have N1 disease.
Lay Summary
Invasive lobular carcinoma (ILC) is a subtype of breast cancer comprising about 15% of cases.
The Oncotype recurrence score (RS) is a genetic test of breast tumors that helps predict which patients might benefit from chemotherapy.
Some have doubted the relevance of the RS for patients with ILC.
In this study, the authors show that the RS is relevant for patients who have ILC.
The RS has the potential of predicting the risk of recurrence and identifying patients with ILC who might benefit from chemotherapy.
This retrospective analysis of data from the National Cancer Database demonstrates the prognostic as well as the predictive value of the Oncotype recurrence score in patients with invasive lobular carcinoma. Those who have invasive lobular carcinoma with a high recurrence score have an overall survival advantage when treated with chemotherapy, much like patients who have invasive ductal carcinoma.
Data on liver transplantation for patients with alcoholic hepatitis are limited. Using the United Network for Organ Sharing database (2004‐2010), adults undergoing liver transplantation for a listing ...diagnosis of alcoholic hepatitis were matched for age, gender, ethnicity, and model for endstage disease (MELD) score, donor risk index, and year of transplantation with three patients transplanted for a listing diagnosis of alcoholic cirrhosis. Study outcomes of graft and patient survival on follow‐up were also analyzed for cohorts based on the diagnosis of the explant (46 alcoholic hepatitis and 138 alcoholic cirrhosis) and diagnosis at both listing as well as of the explant (11 alcoholic hepatitis and 33 alcoholic cirrhosis). Five‐year graft and patient survival of alcoholic hepatitis and alcoholic cirrhosis patients were 75% and 73% (P = 0.97) and 80% and 78% (P = 0.90), respectively. Five‐year graft and patient survival rates were also similar for cohorts based on diagnosis of the explant and diagnosis at listing as well as explant. Cox proportional regression analysis adjusting for other variables showed no impact of the etiology of liver disease (alcoholic hepatitis versus alcoholic cirrhosis) on the graft and patient survival. The causes of graft loss and patient mortality were similar in the two groups, and were not alcohol‐related in any patient. Conclusion: Compared with alcoholic cirrhosis, patients with alcoholic hepatitis have similar posttransplantation graft and patient survival. Based on these preliminary findings, liver transplantation may be considered in a select group of patients with alcoholic hepatitis who fail to improve with medical therapy. Prospective studies are needed to assess the long‐term outcome after liver transplantation in patients with alcoholic hepatitis. (HEPATOLOGY 2012)
Background
Potentially inappropriate medication (PIM) use is a risk factor for hospitalization and mortality. However, there were few studies focusing on the impact of provider type on PIM use.
...Objective
We aimed to estimate the initial and refill PIM prescribing rate for physician visits and nurse practitioner (NP) visits and the impact of provider type on PIM prescribing.
Research Design
We used 100% Texas Medicare data to define physician visits and NP visits in 2016. The rate of visits with a PIM prescription from the same provider was measured, distinguishing between initial and refill prescription to estimate the PIM rate and adjusted odds ratio (OR) by provider type.
Results
There were 24.1 per 1000 visits with a prescription for a PIM: 9.0 per 1000 visits for an initial PIM and 15.1 per 1000 visits for a refill PIM. A visit to an NP was less likely to result in an initial (OR = 0.74, 95% confidence interval CI = 0.70–0.79) or refill (OR = 0.54, 95% CI = 0.51–0.57) PIM. The association of lower odds of receiving a prescription for an initial PIM from an NP was substantially stronger among black enrollees than white enrollees (OR = 0.44, 95%CI = 0.30–0.65 for blacks and OR = 0.73, 95%CI = 0.68–0.78 for white enrollees). The association of an NP provider with lower odds of receiving a PIM refill was more pronounced in older patients and in those with more comorbidities.
Conclusions
NPs prescribed fewer initial PIMs and were less likely to refill a PIM after an outpatient visit than physicians. The lower odds of receiving PIMs during an NP visit varied by age, race/ethnicity, rurality, and number of comorbidities.
Background
The discovery of the BRCA gene in the 1990s created an opportunity for individualized cancer prevention. BRCA testing in young women before cancer onset enables early detection of those ...with an increased cancer risk and creates an opportunity to offer lifesaving prophylactic procedures and medications. This study assessed trends in BRCA testing in women younger than 40 years without diagnosed breast or ovarian cancer (unaffected young women UYW) for cancer prevention between 2006 and 2017 in the United States.
Methods
This study included 93,278 adult women 18 to 65 years old with insurance claims for BRCA testing between 2006 and 2017 from the de‐identified Optum Clinformatics Data Mart database. The data contained medical claims and administrative information from privately insured individuals in the United States. The proportion of BRCA testing in UYW younger than 40 years among adult women aged 18 to 65 years who received BRCA testing was assessed.
Results
In 2006, only 10.5% of the tests were performed in UYW. The proportion of BRCA tests performed in UYW increased significantly to 25.5% in 2017 (annual percentage change for the 2006‐2017 period, 6.9; 95% confidence interval, 6.4‐7.3; P < .001). The increased trend in the proportion of BRCA tests in UYW significantly differed by region of residence and family history of breast or ovarian cancer.
Conclusions
Over the past decade, there was increased use of BRCA testing for cancer prevention. Additional efforts are needed to maximize the early detection of women with BRCA pathogenic variants so that these cancers may be prevented.
Using administrative claims data from one of the largest health insurance companies, this study assesses the use of BRCA testing in unaffected young women (UYW) younger than 40 years during 2006‐2017 and shows that the proportion of UYW receiving testing increased significantly during that period. However, UYW were responsible for only approximately 25% of the tests performed among adult women aged 18 to 65 years in 2017.
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