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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. [ABSTRACT FROM AUTHOR]

THE HRRP AND OBSERVATION HOSPITALIZATIONS The omission of observation hospitalizations from the HRRP "rehospitalization" metric is perhaps the most obvious shortcoming that has emerged.[[6], [8]] Although counterintuitive, hospitalization is not synonymous with inpatient admission. Eliminating observation stays as a separate hospital visit status entirely - meaning all hospital stays would simply be considered hospital inpatient admissions - would be a significant improvement, but this degree of policy shift would have far-reaching implications and is unlikely to happen. According to the MedPAC, from 2006 to 2016, outpatient services increased by 49.0% while inpatient discharges decreased by 21.8%.[15] Although observation is only one type of outpatient service, observation hospital care is nonetheless a significant portion of hospital outpatient services. Both studies included only index inpatient stays, followed by observation I or i inpatient stays within 30 days of the index inpatient stay. [Extracted from the article]

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. [ABSTRACT FROM AUTHOR]

Background: As healthcare systems strive for efficiency, hospital "length of stay outliers" have the potential to significantly impact a hospital's overall utilization. There is a tendency to exclude such "outlier" stays in local quality improvement and data reporting due to their assumed rare occurrence and disproportionate ability to skew mean and other summary data. This study sought to assess the influence of length of stay (LOS) outliers on inpatient length of stay and hospital capacity over a 5-year period at a large urban academic medical center.Methods: From January 2014 through December 2019, 169,645 consecutive inpatient cases were analyzed and assigned an expected LOS based on national academic center benchmarks. Cases in the top 1% of national sample LOS by diagnosis were flagged as length of stay outliers.Results: From 2014 to 2019, mean outlier LOS increased (40.98 to 45.11 days), as did inpatient LOS with outliers excluded (5.63 to 6.19 days). Outlier cases increased both in number (from 297 to 412) and as a percent of total discharges (0.98 to 1.56%), and outlier patient days increased from 6.7 to 9.8% of total inpatient plus observation days over the study period.Conclusions: Outlier cases utilize a disproportionate and increasing share of hospital resources and available beds. The current tendency to exclude such outlier stays in data reporting due to assumed rare occurrence may need to be revisited. Outlier stays require distinct and targeted interventions to appropriately reduce length of stay to both improve patient care and maintain hospital capacity. [ABSTRACT FROM AUTHOR]

Medicare patients hospitalized as inpatients (Part A coverage) are responsible for paying the initial inpatient deductible, after which out-of-pocket costs are capped for the original stay and any subsequent inpatient care in the 60-day benefit period. However, some individual observation hospitalizations (Part B coverage) lack an out-of-pocket limit, and none has a benefit period.[2] Patients experiencing multiple observation hospitalizations, or observation hospitalizations followed by inpatient hospitalizations, may be particularly susceptible to out-of-pocket costs that exceed the inpatient deductible - forcing them to choose between significant financial burden and avoidance of necessary health care. [Extracted from the article]

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 CMSʼ 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. [ABSTRACT FROM AUTHOR]

Since the identification of APOBEC3G (A3G) as a potent restriction factor of HIV-1, a tremendous amount of effort has led to a broadened understanding of both A3G and the APOBEC3 (A3) family to which it belongs. In spite of the fine-tuned viral counterattack to A3 activity, in the form of the HIV-1 Vif protein, enthusiasm for leveraging the Vif : A3G axis as a point of clinical intervention remains high. In an impressive explosion of information over the last decade, additional A3 family members have been identified as antiviral proteins, mechanistic details of the restrictive capacity of these proteins have been elucidated, structure-function studies have revealed important molecular details of the Vif : A3G interaction, and clinical cohorts have been scrutinized for correlations between A3 expression and function and viral pathogenesis. In the last year, novel and unexpected findings regarding the role of A3G in immunity have refocused efforts on exploring the potential of harnessing the natural power of this immune defense. These most recent reports allude to functions of the A3 proteins that extend beyond their well-characterized designation as restriction factors. The emerging story implicates the A3 family as not only defense proteins, but also as participants in the broader innate immune response. [ABSTRACT FROM AUTHOR]

It is now 26 years after the first published report on HIV, and the global epidemic continues unabated, with estimates of over 33 million people currently infected, worldwide. Development of targeted therapies aimed at perturbing the HIV life cycle can be achieved only with a detailed comprehension of the dynamics of virus-host interactions within the cell. One such critical virus-host interaction is the recently elucidated interplay between the viral Vif protein and the innate immune defense molecule Apobec3G. Apobec3G potently suppresses HIV replication, but Vif can alleviate this inhibition, rescuing viral infectivity. Early work describing the characterization of Vif and the cloning and identification of Apobec3G as an antiviral are discussed. Recent advances detailing the mechanisms of the Vif-Apobec3G regulatory circuit and our nascent understanding of Apobec3G endogenous function are also presented. Collectively, these studies have shed light on potential novel therapeutic strategies aimed at exploiting Apobec3G antiviral function to abrogate HIV replication. [ABSTRACT FROM AUTHOR]

The human protein apolipoprotein B mRNA-editing enzyme-catalytic polypeptide-like-3G (APOBEC3G), also known as CEM-15, mediates a newly described form of innate resistance to retroviral infection by catalyzing the deamination of deoxycytidine to deoxyuridine in viral cDNA replication intermediates. Because DNA deamination takes place after virus entry into target cells, APOBEC3G function is dependent on its association with the viral nucleoprotein complexes that synthesize cDNA and must therefore be incorporated into virions as they assemble in infected cells. Here we show that the HIV-1 virion infectivity factor (Vif) protein protects the virus from APOBEC3G-mediated inactivation by preventing its incorporation into progeny virions, thus allowing the ensuing infection to proceed without DNA deamination. In addition to helping exclude APOBEC3G from nascent virions, Vif also removes APOBEC3G from virus-producing cells by inducing its ubiquitination and subsequent degradation by the proteasome. Our findings indicate that pharmacologic strategies aimed at stabilizing APOBEC3G in HIV-1 infected cells should be explored as potential HIV/AIDS therapeutics. [ABSTRACT FROM AUTHOR]

Presents information on a study which described the CEM15 cellular gene. Effect of the cellular gene on HIV-1 replication in T-cells; Methods used in the study.

A principle mechanism of innate immunity to retroviruses is achieved by direct deamination of retroviral first-strand cDNA at some stage during viral replication. DNA deamination targeted to endogenous immunoglobulin loci is used to trigger the diversification of antibodies in the adaptive immune system, DNA deamination targeted to retroviral DNA replication intermediates is used as an innate protection against foreign nucleic acid. The possibility of a mechanistic parallel between central defense pathways of the innate and adaptive immune systems was hinted at originally by the considerable similarity between APOBEC3G, a protein important for innate immunity to human immunodeficiency virus and activation-induced cytidine deaminase syndrome, a protein required for antibody gene diversification.