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Kueiyu Joshua Lin,1,2 Gary E Rosenthal,3 Shawn N Murphy,4,5 Kenneth D Mandl,6 Yinzhu Jin,1 Robert J Glynn,1 Sebastian Schneeweiss1 1Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA; 2Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA; 3Department of Internal Medicine, Wake Forest School of Medicine, Winston-Salem, NC, USA; 4Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA; 5Research Information Science and Computing, Partners Healthcare, Somerville, MA, USA; 6Computational Health Informatics Program, Boston Children’s Hospital, Harvard Medical School, Boston, MA, USACorrespondence: Kueiyu Joshua LinDivision of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, 1620 Tremont St. Suite 3030, Boston, MA 02120, USATel +1 617 278-0930Fax +1 617 232-8602Email jklin@mgh.harvard.eduObjective: Electronic health records (EHR) data-discontinuity, i.e. receiving care outside of a particular EHR system, may cause misclassification of study variables. We aimed to validate an algorithm to identify patients with high EHR data-continuity to reduce such bias.Materials and Methods: We analyzed data from two EHR systems linked with Medicare claims data from 2007 through 2014, one in Massachusetts (MA, n=80,588) and the other in North Carolina (NC, n=33,207). We quantified EHR data-continuity by Mean Proportion of Encounters Captured (MPEC) by the EHR system when compared to complete recording in claims data. The prediction model for MPEC was developed in MA and validated in NC. Stratified by predicted EHR data-continuity, we quantified misclassification of 40 key variables by Mean Standardized Differences (MSD) between the proportions of these variables based on EHR alone vs the linked claims-EHR data.Results: The mean MPEC was 27% in the MA and 26% in the NC system. The predicted and observed EHR data-continuity was highly correlated (Spearman correlation=0.78 and 0.73, respectively). The misclassification (MSD) of 40 variables in patients of the predicted EHR data-continuity cohort was significantly smaller (44%, 95% CI: 40– 48%) than that in the remaining population.Discussion: The comorbidity profiles were similar in patients with high vs low EHR data-continuity. Therefore, restricting an analysis to patients with high EHR data-continuity may reduce information bias while preserving the representativeness of the study cohort.Conclusion: We have successfully validated an algorithm that can identify a high EHR data-continuity cohort representative of the source population.Keywords: electronic medical records, data linkage, comparative effectiveness research, information bias, continuity, external validation

Background Food insecurity (FI) has been associated with an increased atherosclerotic cardiovascular disease (ASCVD) risk; however, the pathways by which FI leads to worse cardiovascular health are unknown. We tested the hypothesis that FI is associated with ASCVD risk through nutritional/anthropometric (eg, worse diet quality and increased weight), psychological/mental health (eg, increased depressive symptoms and risk of substance abuse), and access to care pathways. Methods and Results We conducted a cross‐sectional study of adults (aged 40–79 years) using the 2007 to 2016 National Health and Nutrition Examination Survey. Our primary exposure was household FI, and our outcome was 10‐year ASCVD risk categorized as low (P P P =0.002) pathways. We did not find a significant direct effect of FI on ASCVD risk, and the nutrition, psychological, and access to care pathways accounted for 31.6%, 43.9%, and 15.8% of the association, respectively. Conclusions We found that the association between FI and ASCVD risk category was mediated through the nutrition/anthropometric, psychological/mental health, and access to care pathways. Interventions that address all 3 pathways may be needed to mitigate the negative impact of FI on cardiovascular disease.

Mobile health tools may overcome barriers to social needs screening; however, there are limited data on the feasibility of using these tools in clinical settings. The objective was to determine the feasibility of using a mobile health system to screen for patients' social needs. In one large primary care clinic, the authors tested a tablet-based system that screens patients for social needs, transmits results to the electronic health record, and alerts providers. All adult patients presenting for a nonurgent visit were eligible. The authors evaluated the feasibility of the system and conducted follow-up surveys to determine acceptability and if patients accessed resources through the process. All providers were surveyed. Of the 252 patients approached, 219 (86.9%) completed the screen. Forty-three (19.6%) required assistance with the tablet, and 150 (68.5%) screened positive for at least 1 unmet need (food, housing, or transportation). Of the 150, 103 (68.7%) completed a follow-up survey. The majority agreed that people would learn to use the tablet quickly. Forty-eight patients (46.6%) reported contacting at least 1 community organization through the process. Of the 27 providers, 23 (85.2%) completed a survey and >70% agreed the system would result in patients having better access to resources. It was feasible to use a tablet-based system to screen for social needs. Clinics considering using mobile tools will need to determine how to screen patients who may need assistance with the tool and how to connect patients to resources through the system based on the burden of unmet needs.

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The learning health system (LHS) has gained traction as a powerful framework for improving the cost and quality of healthcare. The goal of an LHS is to systematically integrate internal data and experience with external evidence so patients receive higher-quality, safer, and more efficient care. However, if the goal of an LHS is to improve health, as well as healthcare, it must account for and mitigate the negative impact of social and economic factors on health, known as the social determinants of health. In this paper, we discuss the critical role the LHS can play in addressing patients' social risk factors. We also discuss how integrating data on the social determinants and activities to reduce patients' social risk factors could advance the mission of the LHS to enhance patient engagement, improve the delivery of personalized care, and more accurately evaluate the effectiveness of care. Without the collection and integration of data on the social determinants of health, the LHS may fail to reach its full potential to improve health and healthcare.

BACKGROUND: Numerous studies have examined if food insecurity (FI) leads to increased weight gain, but little is known about how FI affects obese participants. OBJECTIVE: Our objective was to determine if obese, food-insecure adults are more likely to have medical comorbidities than obese, food-secure adults. DESIGN: We conducted a cross-sectional study using the 2007–2014 National Health and Nutrition Examination Survey (NHANES). PARTICIPANTS: All obese participants (≥ 20 years) in NHANES were eligible. Participants who were pregnant or missing FI data were excluded. MAIN MEASURES: The primary exposure was household FI, and the primary outcome was the total number of obesity-related comorbidities. Secondary outcomes evaluated the association between FI and individual comorbidities. Propensity score weighting was used to improve covariate balance. We used negative binomial regression to test the association between FI and the total number of comorbidities. We used logistic regression to test the association between FI and individual comorbidities. KEY RESULTS: Of the 9203 obese participants, 15.6% were food insecure. FI (β = 0.09, 95% CI: 0.02, 0.15; p = 0.01) and very low food security (β = 0.17, 95% CI: 0.07, 0.28; p = 0.003) were associated with an increased number of comorbidities. In secondary analyses, FI was associated with increased odds of coronary artery disease (OR: 1.5, 95% CI: 1.1, 2.0) and asthma (OR: 1.3, 95% CI: 1.1, 1.6). Very low food security was associated with increased odds of coronary artery disease, diabetes, and asthma. CONCLUSION: Obese adults living in food-insecure households were more likely to have an increased number of comorbid conditions than obese adults living in food-secure households. Clinicians should be aware of the association between FI and comorbid medical conditions when treating patients with obesity. ELECTRONIC SUPPLEMENTARY MATERIAL: The online version of this article (10.1007/s11606-019-05081-9) contains supplementary material, which is available to authorized users.

Objective The study sought to design, pilot, and evaluate a federated data completeness tracking system (CTX) for assessing completeness in research data extracted from electronic health record data across the Accessible Research Commons for Health (ARCH) Clinical Data Research Network. Materials and Methods The CTX applies a systems-based approach to design workflow and technology for assessing completeness across distributed electronic health record data repositories participating in a queryable, federated network. The CTX invokes 2 positive feedback loops that utilize open source tools (DQe-c and Vue) to integrate technology and human actors in a system geared for increasing capacity and taking action. A pilot implementation of the system involved 6 ARCH partner sites between January 2017 and May 2018. Results The ARCH CTX has enabled the network to monitor and, if needed, adjust its data management processes to maintain complete datasets for secondary use. The system allows the network and its partner sites to profile data completeness both at the network and partner site levels. Interactive visualizations presenting the current state of completeness in the context of the entire network as well as changes in completeness across time were valued among the CTX user base. Discussion Distributed clinical data networks are complex systems. Top-down approaches that solely rely on technology to report data completeness may be necessary but not sufficient for improving completeness (and quality) of data in large-scale clinical data networks. Improving and maintaining complete (high-quality) data in such complex environments entails sociotechnical systems that exploit technology and empower human actors to engage in the process of high-quality data curating. Conclusions The CTX has increased the network’s capacity to rapidly identify data completeness issues and empowered ARCH partner sites to get involved in improving the completeness of respective data in their repositories.

Introduction: To produce results from clinical trials that are statistically significant, researchers must enroll enough participants; however, it is difficult to recruit sufficient participants. The ADAPTABLE trial is a pragmatic randomized controlled trial designed to compare two aspirin doses in patients with cardiovascular disease. Methods: We used eligibility criteria set forth by the ADAPTABLE study protocol. We then put patients into two groups. Patients with email addresses were group one, and sent an email weekly. Patients without an email address were in group two, and a letter was mailed to their home address. Eligible patients who had a clinic appointment scheduled were also recruited approached in clinic. Most of these patients had already been stratified into the email or letter group, but there was the possibility that they had a new diagnosis and had not been contacted. All were given a link to the ADAPTABLE trial portal with an access code to enroll. An explanatory video about the study and electronic informed consent were on the trial website. Results: As shown in Table 1, four hundred and nine patients enrolled in our trial over a 10-month period. Three hundred and ninety-seven (97.06%) patients enrolled in the study via email. Letters were sent to 7,226 patients and four (0.98%) enrolled in the study. Eight (1.96%) of the patients who were approached in person enrolled in the study. The cost of email campaign was $1.44/patient and the cost per enrollment was the least expensive, at $95.71. In person enrollment cost $23.34/patient and the total cost per enrollment was $417.12. The letter recruitment cost $0.30/patient, however, the cost per enrollment was the highest, at $542.26. Conclusion: Email is an effective and economical way to recruit patients for clinical trials. Email allows researchers to contact more patients about proposed studies promptly and facilitates pragmatic research trials that achieve results in a timely and cost-efficient manner.

OBJECTIVES: Optimizing care for patients with advanced kidney disease requires close collaboration between primary care physicians (PCPs) and nephrologists. Factors associated with PCP referral to nephrology were assessed in patients with estimated glomerular filtration rates (eGFRs) less than 30 mL/min/1.73 m(2). STUDY DESIGN: Electronic health record review at an integrated health care network. METHODS: Factors associated with referral status were identified using Fisher’s exact tests, t tests, and multivariable logistic regression. RESULTS: Of 133,913 patients regularly seeing PCPs between October 2017 and September 2019, 1119 had a final eGFR less than 30 mL/min/1.73 m(2) and were not on renal replacement therapy. Care was provided by 185 PCPs (61 practices). Analyses were restricted to the 97.1% (n = 1087) of patients who were African American or European American. Of these, 54.6% had not been referred to nephrology. Nonreferred patients had higher numbers of PCP visits (P = .004). In contrast, referred patients were younger, were more often African American, and had PCPs at the academic medical center (all P

BackgroundEffective communication between healthcare providers and patients and their family members is an integral part of daily care and discharge planning for hospitalised patients. Several studies suggest that team-based care is associated with improved length of stay (LOS), but the data on readmissions are conflicting. Our study evaluated the impact of structured interdisciplinary bedside rounding (SIBR) on outcomes related to readmissions and LOS.MethodsThe SIBR team consisted of a physician and/or advanced practice provider, bedside nurse, pharmacist, social worker and bridge nurse navigator. Outcomes were compared in patients admitted to a hospital medicine unit using SIBR (n=1451) and a similar control unit (n=770) during the period of October 2016 to September 2017. Multivariable negative binomial regression analysis was used to compare LOS and logistic regression analysis was used to calculate 30-day and 7-day readmission in patients admitted to SIBR and control units, adjusting for covariates.ResultsPatients admitted to SIBR and control units were generally similar (p≥0.05) with respect to demographic and clinical characteristics. Unadjusted readmission rates in SIBR patients were lower than in control patients at both 30 days (16.6% vs 20.3%, p=0.03) and 7 days (6.3% vs 9.0%, p=0.02) after discharge, while LOS was similar. After adjusting for covariates, SIBR was not significantly related to the odds of 30-day readmission (OR 0.81, p=0.07) but was lower for 7-day readmission (OR 0.70, p=0.03); LOS was similar in both groups (p=0.58).ConclusionSIBR did not reduce LOS and 30-day readmissions but had a significant impact on 7-day readmissions.

Digital informed consent may better inform individuals about health research and increase participation. In the United States and elsewhere, minorities and rural populations are underrepresented in health research and may benefit from well-designed electronic informed consent (eIC). Seven focus groups were conducted with 50 Caucasian, African American, and rural patients in the United States. Participants were asked their preferences for a paper versus electronic informed consent document. Participants found the e-version easier to use, more interesting, and better for understanding. Minority participants emphasized limited access, computer literacy, and trust barriers to eIC. Rural participants were concerned about accessibility, connectivity, privacy, and confidentiality. People see value in electronic consenting. Researchers should consider barriers to eIC among underrepresented populations before recruitment.

© 2017 The Author(s). Background: The clinical research enterprise is not producing the evidence decision makers arguably need in a timely and cost effective manner; research currently involves the use of labor-intensive parallel systems that are separate from clinical care. The emergence of pragmatic clinical trials (PCTs) poses a possible solution: these large-scale trials are embedded within routine clinical care and often involve cluster randomization of hospitals, clinics, primary care providers, etc. Interventions can be implemented by health system personnel through usual communication channels and quality improvement infrastructure, and data collected as part of routine clinical care. However, experience with these trials is nascent and best practices regarding design operational, analytic, and reporting methodologies are undeveloped. Methods: To strengthen the national capacity to implement cost-effective, large-scale PCTs, the Common Fund of the National Institutes of Health created the Health Care Systems Research Collaboratory (Collaboratory) to support the design, execution, and dissemination of a series of demonstration projects using a pragmatic research design. Results: In this article, we will describe the Collaboratory, highlight some of the challenges encountered and solutions developed thus far, and discuss remaining barriers and opportunities for large-scale evidence generation using PCTs. Conclusion: A planning phase is critical, and even with careful planning, new challenges arise during execution; comparisons between arms can be complicated by unanticipated changes. Early and ongoing engagement with both health care system leaders and front-line clinicians is critical for success. There is also marked uncertainty when applying existing ethical and regulatory frameworks to PCTS, and using existing electronic health records for data capture adds complexity.

International implementation of the patient-centered medical home (PCMH) model for delivering primary care has dramatically increased in the last decade. A majority of research on PCMH's impact has emphasized the care provided by clinically trained staff. In this article, we report our ethnographic analysis of data collected from Department of Veterans Affairs staff implementing PACT, the VA version of PCMH. Teams were trained to use within-team delegation, largely accomplished through attention to clinical licensure, to differentiate staff in providing efficient, patient-centered care. In doing so, PACT may reinforce a clinically defined culture of care that countermands PCMH ideals. Such competing rubrics for care are brought into relief through a focus on the care work performed by clerks. Ethnographic analysis identifies clerks' care as a kind of emotional dirty work, signaling important areas for future anthropological study of the relationships among patient-centered care, stigma, and clinical authority.

The experiences of RNs and licensed practical nurses (LPNs) implementing a patient-centered medical home (PCMH) in the Department of Veterans Affairs (VA) primary care clinics were examined to understand model implications for nursing practice and professional identity.National implementation of the PCMH model, called patient-aligned care teams (PACTs) in VA, emphasizes areas of nursing expertise, yet little is known about the effect of medical homes on the day-to-day work of nurses.As part of a formative evaluation to identify barriers and facilitators to PACT implementation, we interviewed 18 nurses implementing PACT.Challenges to nurse's organizational and professional roles were experienced differently by RNs and LPNs in the following areas: (1) diversified modes of care and expanded clinical duties, (2) division of labor among PACT nurses, and (3) interprofessional status in the team.Healthcare managers implementing PCMH should consider its inherent cultural and practice transformations.

Importance Suicide is a leading cause of mortality, with suicide-related deaths increasing in recent years. Automated methods for individualized risk prediction have great potential to address this growing public health threat. To facilitate their adoption, they must first be validated across diverse health care settings. Objective To evaluate the generalizability and cross-site performance of a risk prediction method using readily available structured data from electronic health records in predicting incident suicide attempts across multiple, independent, US health care systems. Design, Setting, and Participants For this prognostic study, data were extracted from longitudinal electronic health record data comprisingInternational Classification of Diseases, Ninth Revisiondiagnoses, laboratory test results, procedures codes, and medications for more than 3.7 million patients from 5 independent health care systems participating in the Accessible Research Commons for Health network. Across sites, 6 to 17 years’ worth of data were available, up to 2018. Outcomes were defined byInternational Classification of Diseases, Ninth Revisioncodes reflecting incident suicide attempts (with positive predictive value >0.70 according to expert clinician medical record review). Models were trained using naive Bayes classifiers in each of the 5 systems. Models were cross-validated in independent data sets at each site, and performance metrics were calculated. Data analysis was performed from November 2017 to August 2019. Main Outcomes and Measures The primary outcome was suicide attempt as defined by a previously validated case definition usingInternational Classification of Diseases, Ninth Revisioncodes. The accuracy and timeliness of the prediction were measured at each site. Results Across the 5 health care systems, of the 3 714 105 patients (2 130 454 female [57.2%]) included in the analysis, 39 162 cases (1.1%) were identified. Predictive features varied by site but, as expected, the most common predictors reflected mental health conditions (eg, borderline personality disorder, with odds ratios of 8.1-12.9, and bipolar disorder, with odds ratios of 0.9-9.1) and substance use disorders (eg, drug withdrawal syndrome, with odds ratios of 7.0-12.9). Despite variation in geographical location, demographic characteristics, and population health characteristics, model performance was similar across sites, with areas under the curve ranging from 0.71 (95% CI, 0.70-0.72) to 0.76 (95% CI, 0.75-0.77). Across sites, at a specificity of 90%, the models detected a mean of 38% of cases a mean of 2.1 years in advance. Conclusions and Relevance Across 5 diverse health care systems, a computationally efficient approach leveraging the full spectrum of structured electronic health record data was able to detect the risk of suicidal behavior in unselected patients. This approach could facilitate the development of clinical decision support tools that inform risk reduction interventions.

Objective Up to 70 percent of patients who receive care through Veterans Health Administration (VHA) facilities also receive care from non-VA providers. Using applied classification techniques, this study sought to improve understanding of how elderly VA patients use VA services and complementary use of non-VA care. Methods The study included 1,721,900 veterans age 65 and older who were enrolled in VA and Medicare during 2013 with at least one VA encounter during 2013. Outpatient and inpatient encounters and medications received in VA were classified, and mutually exclusive patient subsets distinguished by patterns of VA service use were derived empirically using latent class analysis (LCA). Patient characteristics and complementary use of non-VA care were compared by patient subset. Results Five patterns of VA service use were identified that were distinguished by quantity of VA medical and specialty services, medication complexity, and mental health services. Low VA Medical users tend to be healthier and rely on non-VA services, while High VA users have multiple high cost illnesses and concentrate their care in the VA. Conclusions VA patients distinguished by patterns of VA service use differ in illness burden and the use of non-VA services. This information may be useful for framing efforts to optimize access to care and care coordination for elderly VA patients.

Implementation of a patient centered medical home challenges primary care providers to change their scheduling practices to enhance patient access to care as well as to learn how to use performance metrics as part of a self-reflective practice redesign culture. As medical homes become more commonplace, health care administrators and primary care providers alike are eager to identify barriers to implementation. The objective of this study was to identify non-technological barriers to medical home implementation from the perspective of primary care providers. We conducted qualitative interviews with providers implementing the medical home model in Department of Veterans Affairs clinics-the most comprehensive rollout to date. Primary care providers reported favorable attitudes towards the model but discussed the importance of data infrastructure for practice redesign and panel management. Respondents emphasized the need for administrative leadership to support practice redesign by facilitating time for panel management and recognizing providers who utilize non-face-to-face ways of delivering clinical care. Health care systems considering adoption of the medical home model should ensure that they support both technological capacities and vertically aligned expectations for provider performance.

Research evaluating the effectiveness, function, and implementation of patient-centered medical homes (PCMHs) has found major socioprofessional transformations and contributions of primary care physicians and, to a lesser degree, nurses. Our longitudinal ethnographic research with teams implementing PCMH in Veterans Health Administration (VHA) primary care identifies the important but largely underutilized contributions of clerks to PCMH outcomes. Although the relationship of high-performing clerical staff to patient satisfaction is widely acknowledged, PCMH can be further enhanced by enabling clerks to use administrative tasks as conduits for investing in long-term personalized relationships with patients that foster trust in the PCMH and the broader health care organization. Such relationships are engendered through the care-coordination activities clerks perform, which may be bolstered by organizational investment in clerks as skilled health care team members.

The Patient-Centered Medical Home (PCMH) is a leading model of primary care reform, a critical element of which is payment reform for primary care services. With the passage of the Affordable Care Act, the Accountable Care Organization (ACO) has emerged as a model of delivery system reform, and while there is theoretical alignment between the PCMH and ACOs, the discussion of physician payment within each model has remained distinct. Here we compare payment for medical homes with that for accountable care organizations, consider opportunities for integration, and discuss implications for policy makers and payers considering ACO models. The PCMH and ACO are complementary approaches to reformed care delivery: the PCMH ultimately requires strong integration with specialists and hospitals as seen under ACOs, and ACOs likely will require a high functioning primary care system as embodied by the PCMH. Aligning payment incentives within the ACO will be critical to achieving this integration and enhancing the care coordination role of primary care in these settings.

Blood pressure exhibits circadian variability, and nighttime blood pressure is one of the best predictors of cardiovascular (CV) events. Adults with hypertension who lack a nighttime dipping pattern are at particularly high risk. Several studies have found that bedtime dosing of antihypertensive agents reduces sleep blood pressure and improves the dipping pattern in nondippers. One small study and 2 substudies of diabetes and chronic kidney disease suggest that bedtime dosing of ≥ 1 antihypertensives significantly reduced CV events. A Cochrane review of 5 studies found no difference in adverse events between morning and evening dosing. However, several evaluations in ophthalmology have found that nocturnal arterial hypotension precipitated ocular vascular disorders such as ischemic optic neuropathy. Some authors have suggested that additional studies of nighttime dosing of antihypertensive agents that evaluate CV events need to be conducted. The authors describe a randomized controlled pragmatic trial that is being planned at the University of Iowa and Duke University. Patients with hypertension and other comorbid conditions will be randomized to either continue morning dosing of all antihypertensive agents or to switch their nondiuretic medications to bedtime dosing. Patients will be followed for 36 to 42 months. This study will determine whether nighttime dosing reduces CV risk when compared with traditional morning dosing of antihypertensive agents.

Policies limiting exposure to cigarette smoke have been associated with reduced hospitalizations for heart attacks, but little is known about the impact of smoking bans on other health conditions and whether findings from individual communities generalize to other areas. We investigated the association between smoking bans targeting workplaces, restaurants, and bars passed throughout the United States during 1991-2008 and hospital admissions for smoking-related illnesses-acute myocardial infarction and chronic obstructive pulmonary disease-among Medicare beneficiaries age sixty-five or older. Risk-adjusted hospital admission rates for acute myocardial infarction fell 20-21 percent thirty-six months following implementation of new restaurant, bar, and workplace smoking bans. Admission rates for chronic obstructive pulmonary disease fell 11 percent where workplace smoking bans were in place and 15 percent where bar smoking bans were present. By contrast, very little effect was found for hospitalization for gastrointestinal hemorrhage and hip fracture-two conditions largely unrelated to smoking and examined as points of comparison. These findings provide further support for the public health benefits of laws that limit exposure to tobacco smoke.

International implementation of the patient-centered medical home (PCMH) model for delivering primary care has dramatically increased in the last decade. A majority of research on PCMH's impact has emphasized the care provided by clinically trained staff. In this article, we report our ethnographic analysis of data collected from Department of Veterans Affairs staff implementing PACT, the VA version of PCMH. Teams were trained to use within-team delegation, largely accomplished through attention to clinical licensure, to differentiate staff in providing efficient, patient-centered care. In doing so, PACT may reinforce a clinically defined culture of care that countermands PCMH ideals. Such competing rubrics for care are brought into relief through a focus on the care work performed by clerks. Ethnographic analysis identifies clerks' care as a kind of emotional dirty work, signaling important areas for future anthropological study of the relationships among patient-centered care, stigma, and clinical authority.

Home telehealth programs often focus on a single disease, yet many patients who need monitoring have multiple conditions. This study evaluated secondary outcomes from a clinical trial evaluating the efficacy of home telehealth to improve outcomes of patients with co-morbid diabetes and hypertension.A single-center randomized controlled clinical trial compared two remote monitoring intensity levels (low and high) and usual care in patients with type 2 diabetes and hypertension being treated in primary care. Secondary outcomes assessed were knowledge (diabetes, hypertension, medications), self-efficacy, adherence (diabetes, medications), and patient perceptions of the intervention mode.Knowledge scores improved in the high-intensity intervention group participants, but upon further analysis, we found the intervention effect was not mediated by gain in knowledge. No significant differences were found across the groups in self-efficacy, adherence, or patient perceptions of the intervention mode.Home telehealth can enhance detection of key clinical symptoms that occur between regular physician visits. While our intervention improved glycemic and blood pressure control, the mechanism of the effect for this improvement was not clear.

Evidence indicates that veterans using VA healthcare services have poor health-related quality of life (HRQOL). Little is known, however, about differences in HRQOL among those who only use VA services and those who also use non-VA services. We sought to evaluate differences in HRQOL among veterans who use: (1) only non-VA services (2) only VA services and (3) both VA and non-VA services (i.e., dual users). A cross-sectional study of 39,942 US veterans who completed the CDC’s 2004 Behavioral Risk Factor Surveillance System (BRFSS) survey was analyzed. Self-rated measures of global health status and the number of days per month that veterans were limited by physical or mental problems were extracted from BRFSS survey data as outcomes. Multivariate logistic regression demonstrated that, compared to those receiving all healthcare outside of VA, veterans receiving VA care were more likely to report poorer health outcomes, including worse global health status, greater impairments in physical functioning, and increased limitations regarding routine activities (p’s ≤ .05). Both exclusive and dual users of VA services reported poorer HRQOL than individuals not using VA services. More research is needed regarding veterans’ health status, particularly in the context of dual use.

Increased emphasis is being placed on the critical need to control hypertension (HTN) in patients with diabetes.The objective of this study was to evaluate the efficacy of a nurse-managed home telehealth intervention to improve outcomes in veterans with comorbid diabetes and HTN.A single-center, randomized, controlled clinical trial design comparing two remote monitoring intensity levels and usual care in patients with type 2 diabetes and HTN being treated in primary care was used.Primary outcomes were hemoglobin A1c and systolic blood pressure (SBP); secondary outcome was adherence.Intervention subjects experienced decreased A1c during the 6-month intervention period compared with the control group, but 6 months after the intervention was withdrawn, the intervention groups were comparable with the control group. For SBP, the high-intensity subjects had a significant decrease in SBP compared with the other groups at 6 months and this pattern was maintained at 12 months. Adherence improved over time for all groups, but there were no differences among the three groups.Subjects had relatively good baseline control for A1c and SBP; minorities and women were underrepresented.Home telehealth provides an innovative and pragmatic approach to enhance earlier detection of key clinical symptoms requiring intervention. Transmission of education and advice to the patient on an ongoing basis with close surveillance by nurses can improve clinical outcomes in patients with comorbid chronic illness.

Specialty hospitals have lower mortality rates for cardiac revascularization than general hospitals, but previous studies have found that this advantage disappears after adjusting for patient characteristics and hospital procedural volume. Questions have been raised about whether simultaneous relationships between volume and mortality might have biased these analyses. We use two-stage least squares with Hospital Quality Alliance scores and estimated market size as instruments for mortality and volume to control for possible simultaneity. After this adjustment, it is still the case that specialty hospitals do not have an advantage over general hospitals in mortality rates after cardiac revascularization. We find evidence of simultaneity in the relationship between volume and mortality.

Purpose To examine the effects of preexisting comorbid psychiatric conditions on mortality in a large cohort of patients admitted to a nonsurgical intensive care unit. Methods This retrospective cohort study involved 66 672 consecutive eligible nonsurgical patients admitted to intensive care units in 129 Veterans Health Administration hospitals during 2005 and 2006. Preexisting comorbid psychiatric conditions were identified by using diagnoses from outpatient encounters in the prior year for depression, anxiety, psychosis, bipolar disorders, and posttraumatic stress disorder. Generalized estimating equations were used to adjust the risks of inhospital and 30-day mortality for demographics, comorbid medical conditions, markers of severity, and abnormal findings on laboratory tests at admission. Results Comorbid psychiatric conditions were identified in 28% (n = 18 698) of patients. Patients with preexisting comorbid psychiatric conditions had lower (P < .001) unadjusted inhospital mortality (7.3% vs 8.7%) and 30-day mortality (10.0% vs 12.8%) than did patients without such conditions. After demographics, comorbid medical conditions, and severity were adjusted for, risk of in-hospital mortality among patients with comorbid psychiatric conditions was somewhat higher (odds ratio, 1.07, 95% confidence interval, 1.01–1.14; P = .02), although differences in 30-day mortality (odds ratio, 1.01, 95% confidence interval, 0.94–1.08; P = .70) were no longer significant. Conclusion Preexisting comorbid psychiatric conditions are common among intensive care patients, but after comorbid medical conditions and severity were adjusted for, preexisting comorbid psychiatric conditions were not associated with a higher risk of 30-day mortality in a large national cohort of veterans.

Objective: The objective of this study was to describe the epidemiology, clinical features, outcomes, and predictors of mortality in veterans with peripheral artery disease (PAD). Methods: We used national data from the Veterans Health Administration from fiscal years 2009 to 2011 to identify patients with a new diagnosis of PAD. Within this cohort, we describe characteristics of the patients, use of recommended medications, and clinical outcomes during a 3-year follow-up (fiscal year 2014). We used Cox proportional hazards regression to examine predictors of mortality and adverse limb outcomes (amputation and hospitalization for critical limb ischemia [CLI]) during follow-up. Results: A total of 175,865 patients with a new diagnosis of PAD were included. The mean age was 69.9 years; 97.8% were male, and 67.7% were white. Nearly 77% of patients had hypertension, 46.5% had diabetes, 23% had chronic obstructive pulmonary disease, and 12.9% had renal failure. A prescription for statins was filled by 60.8%, and 34.9% received high-intensity statins within 90 days of PAD diagnosis. At 1 year, 2.6% underwent revascularization, 1.3% developed CLI, and 1.1% underwent amputation. During a median follow-up of 3.8 years, a total of 28.6% patients died (6.7% at 1 year), and 3.7% developed a limb outcome (2.0% at 1 year). Predictors of mortality included advanced age, comorbidities, and CLI or amputation at presentation. In contrast, prescription with statins was associated with lower mortality. Similar findings were present with regard to predictors of adverse limb outcomes, except that older age was associated with a lower risk of amputation or CLI. Conclusions: We found that veterans with PAD have a high prevalence of comorbid conditions and have a significant risk of mortality and limb loss. A substantial proportion of veterans with PAD are not prescribed recommended medications, especially statin therapy. Our data highlight important opportunities for improving care of veterans with PAD. (J Vasc Surg 2018; 68:527–35.)

Each July, teaching hospitals experience an influx of new residents and fellows who recently have graduated from medical school or completed residency training programs. During this period, teaching hospitals also assign new positions of responsibility to existing residents and fellows. Medical education is a core mission of teaching hospitals, and, in these hospitals, interns, residents, and fellows play major roles in patient care. This recurrent cycle in which care is delivered by less experienced physicians in the initial month of the academic year has led to the often expressed conventional wisdom of “not to get sick in July.”1 Article see p 2754 In addition to the lore surrounding July admissions to teaching hospitals, previous studies have shown that physician experience is an important determinant of outcomes for a wide range of medical conditions and procedures.2–5 Moreover, literature from economics and other fields has shown that employee turnover can adversely affect organizational productivity.6,7 Given that teaching hospitals face both inexperienced physicians as well as high turnover early in the academic year, it is reasonable to be concerned about the potential for lower quality care around that time. Based on these concerns, a number of studies over the past 25 years have compared patient outcomes in teaching hospitals during July and later months of the academic year. Indeed, a recent systematic review by Young et al6 identified 39 studies that examined care delivered in a wide range of clinical settings, including inpatient medical and surgical wards, intensive care units, operating rooms, and emergency rooms. Of these 39 studies, 27 (69%) evaluated hospital mortality, and of these 27 studies, only 6 (22%) found higher mortality among patients who received care in July or the early months of the academic year associated with housestaff turnover. However, …

Background. We examined whether older adults who had continuity of care with a primary care physician (PCP) had lower mortality. Methods. Secondary analyses were conducted using baseline interview data (19931994) from the nationally representative Survey on Assets and Health Dynamics among the Oldest Old (AHEAD). The analytic sample included 5,457 self-respondents 70 years old or more who were not enrolled in managed care plans. AHEAD data were linked to Medicare claims for 19912005, providing up to 12 years of follow-up. Two time-dependent measures of continuity addressed whether there was more than an 8-month interval between any two visits to the same PCP during the prior 2-year period. The present exposure measure calculated this criterion on a daily basis and could switch on or off daily, whereas the cumulative exposure measure reflected the percentage of follow-up days, also on a daily basis allowing it to switch on or off daily, for which the criterion was met. Results. Two thousand nine hundred and fifty-four (54%) participants died during the follow-up period. Using the cumulative exposure measure, 27% never had continuity of care, whereas 31%, 20%, 14%, and 8%, respectively, had continuity for 1%33%, 34%67%, 68%99%, and 100% of their follow-up days. Adjusted for demographics, socioeconomic status, social support, health lifestyle, and morbidity, both measures of continuity were associated (p < .001) with lower mortality (adjusted hazard ratios of 0.84 for the present exposure measure and 0.31, 0.39, 0.46, and 0.62, respectively, for the 1%33%, 34%67%, 68%99%, and 100% categories of the cumulative exposure measure). Conclusion. Continuity of care with a PCP, as assessed by two distinct measures, was associated with substantial reductions in long-term mortality.

The Department of Veterans Affairs (VA) National Quality Scholars Fellowship Program (VAQS) was established in 1998 as a postgraduate medical education fellowship to train physicians in new methods of improving the quality and safety of health care for veterans and the nation. The VAQS curriculum is based on adult learning theory, with a national core curriculum of face-to-face components, technologically mediated distance learning components, and a unique local curriculum that draws from the strengths of regional resources. VAQS has established strong ties with other VA programs. Fellows' research and quality improvement projects are integrated with local and regional VA leaders' priorities, enhancing the relevance and visibility of the fellows' efforts and promoting recruitment of fellows to VA positions. VAQS has enrolled 98 fellows since 1999; 75 have completed the program and 24 are currently enrolled. Fellowship graduates have pursued a variety of career paths: 17% are continuing training (most in VA), 31% hold a VA faculty/staff position, 66% are academic faculty, and 80% conduct clinical or research work related to health care improvement. Graduates have held leadership positions in VA, Department of Defense, academic medicine, and public health agencies. Combining knowledge about the improvement of health care with adult learning strategies, distance learning technologies, face-to-face meetings, local mentorship, and experiential projects has been successful in improving care in VA and preparing physicians to participate in, study, and lead the improvement of health care quality and safety.

The authors prospectively explored the consequences of hip fracture with regard to discharge placement, functional status, and mortality using the Survey on Assets and Health Dynamics Among the Oldest Old (AHEAD). Data from baseline (1993) AHEAD interviews and biennial follow-up interviews were linked to Medicare claims data from 1993-2005. There were 495 postbaseline hip fractures among 5,511 respondents aged >or=69 years. Mean age at hip fracture was 85 years; 73% of fracture patients were white women, 45% had pertrochanteric fractures, and 55% underwent surgical pinning. Most patients (58%) were discharged to a nursing facility, with 14% being discharged to their homes. In-hospital, 6-month, and 1-year mortality were 2.7%, 19%, and 26%, respectively. Declines in functional-status-scale scores ranged from 29% on the fine motor skills scale to 56% on the mobility index. Mean scale score declines were 1.9 for activities of daily living, 1.7 for instrumental activities of daily living, and 2.2 for depressive symptoms; scores on mobility, large muscle, gross motor, and cognitive status scales worsened by 2.3, 1.6, 2.2, and 2.5 points, respectively. Hip fracture characteristics, socioeconomic status, and year of fracture were significantly associated with discharge placement. Sex, age, dementia, and frailty were significantly associated with mortality. This is one of the few studies to prospectively capture these declines in functional status after hip fracture.

OBJECTIVE: This study examines two dimensions of racial segregation across hospitals, using a disease for which substantial disparities have been documented. DATA SOURCES: Black (n=32,289) and white (n=244,042) patients 67 years and older admitted for acute myocardial infarction during 2004-2005 in 105 hospital markets were identified from Medicare data. Two measures of segregation were calculated: Dissimilarity (i.e., dissimilar distribution by race across hospitals), and Isolation (i.e., racial isolation within hospitals). For each measure, markets were categorized as having low, medium, or high segregation. STUDY DESIGN: The relationship of hospital segregation to residential segregation and other market characteristics was evaluated. Cox proportional hazards regression was used to evaluate disparities in the use of revascularization within 90 days by segregation level. RESULTS: Agreement of segregation category based on Dissimilarity and Isolation was poor (kappa=0.12), and the relationship of disparities in revascularization to segregation differed by measure. The hazard of revascularization for black relative to white patients was lowest (i.e., greatest disparity) in markets with low Dissimilarity, but it was unrelated to Isolation. CONCLUSIONS: Significant racial segregation across hospitals exists in many U.S. markets, although the magnitude and relationship to disparities depends on definition. Dissimilar distribution of race across hospitals may reflect divergent cultural preferences, social norms, and patient assessments of provider cultural competence, which ultimately impact utilization.

This study compared mortality in African American and white patients admitted to veterans affairs (VA) hospitals for chronic obstructive pulmonary disease (COPD) exacerbation and determined the potential impact of differences in intensive care unit (ICU) admission and mechanical ventilation. Administrative data from 2003-2006 identified African American (n = 7159) and white (n = 43820) patients admitted to VA hospitals with COPD exacerbation. Hierarchical logistic regression was used to compare risk-adjusted 30-day or inhospital mortality in African American and white patients. African Americans were more likely than whites to be admitted to ICUs (19.1% vs 17.2%, respectively; p.001) and to receive mechanical ventilation (4.8% vs 4.1%, p.001). African Americans had lower unadjusted mortality than white patients overall (7.1% vs 9.2%, p.001), and among patients admitted to ICUs (16.9% vs 20.3%, p.01) and non-ICU wards (4.8% vs 6.9%, p.001). Mortality was similar for African Americans and whites receiving mechanical ventilation (28.8% vs 31.4%, p = .34). The risk-adjusted odds of death were lower for African Americans relative to white patients (OR, 0.71; p.001) and in analyses that further adjusted for ICU admission and ventilation use (OR, 0.69; p.001). Mortality was lower in African Americans than white veterans admitted for COPD exacerbation, even after adjusting for differences in ICU admission rates and ventilatory support. The lower risk-adjusted mortality in African Americans was not explained by more aggressive care.

This study compares the likelihood of admission to high-mortality hospitals for black and white Medicare patients in 118 health care markets, and whether admission patterns vary if residential racial segregation is greater in the area. Risk of admission to high-mortality hospitals was 35 percent higher for blacks than for whites in markets with high residential segregation. Moreover, blacks were more likely than whites to be admitted to hospitals with high mortality, even in analyses limited to patients who lived closest to lower-mortality hospitals. Eliminating health care disparities may require policies that address social factors leading to segregation.

Background: Black patients are more likely than white patients to prefer and receive more life-sustaining interventions in advanced stages of disease. However, little is known about potential racial differences in use of mechanical ventilation (MV), and the newer modality of noninvasive ventilation (NIV), in treatment of chronic obstructive pulmonary disease (COPD). Objective: To determine if rates of MV and NIV use differ among black and white patients admitted to Veterans Administration (VA) hospitals for COPD exacerbation. Research Design: Retrospective cohort analysis of VA database FY2003 to FY2005 including 153 hospitals nationwide. Subjects: All black (n = 5479) and white (n = 31,537) patients admitted with COPD exacerbation. Measures: Ventilation use during hospitalization as identified by ICD-9-CM codes for MV and NIV. Hierarchical logistic regression compared rates of MV or NIV use among black and white patients, adjusting for patient characteristics and accounting for hospital-level variation. Results: Unadjusted rates of MV were higher in black patients than in white patients (4.1% vs. 3.0%; P < 0.001), but similar for NIV (6.0% vs. 6.1%; P = 0.65). The adjusted odds of MV for black patients relative to white patients remained higher (OR = 1.27, 95% CI: 1.01-1.54; P < 0.01) while the adjusted odds of NIV remained similar (OR = 0.94, 95% CI: 0.82-1.08; P = 0.38). Conclusions: Black patients with COPD exacerbation in VA hospitals are more likely than white patients to receive MV, and this difference is not explained by available clinical or demographic variables. By contrast, black and white patients are equally likely to receive NIV. These findings suggest that unmeasured factors, such as patient preferences or disease severity, may be affecting the use of MV in this setting and therefore warrant further investigation.

Previous studies have found that home-based intervention programs reduce readmission rates for patients with heart failure. Only one previous trial has compared telephone and videophone to traditional care to deliver a home-based heart failure intervention program. The objective of this study was to evaluate the efficacy of a telehealth-facilitated postdischarge support program in reducing resource use in patients with heart failure. Patients at a Midwestern Department of Veterans Affairs Medical Center were randomized to telephone, videophone, or usual care for follow-up care after hospitalization for heart failure exacerbation. Outcome measures included readmission rates; time to first readmission; urgent care clinic visits; survival; and quality of life. The intervention resulted in a significantly longer time to readmission but had no effect on readmission rates or mortality. There were no differences in hospital days or urgent care clinic use. All subjects reported higher disease-specific quality of life scores at 1 year. There was evidence of the value of telephone follow-up, but there was no evidence to support the benefit of videophone care over telephone care. Rigorous evaluation is needed to determine which patients may benefit most from specific telehealth applications and which technologies are most cost-effective.

Background: Discussions about medical errors facilitate professional learning for physicians and may provide emotional support after an error, but little is known about physicians’ attitudes and practices regarding error discussions with colleagues. Methods: Survey of faculty and resident physicians in generalist specialties in Midwest, Mid-Atlantic and Northeast regions of the US to investigate attitudes and practices regarding error discussions, likelihood of discussing hypothetical errors, experience role-modelling error discussions and demographic variables. Results: Responses were received from 338 participants (response rate = 74%). In all, 73% of respondents indicated they usually discuss their mistakes with colleagues, 70% believed discussing mistakes strengthens professional relationships and 89% knew at least one colleague who would be a supportive listener. Motivations for error discussions included wanting to learn whether a colleague would have made the same decision (91%), wanting colleagues to learn from the mistake (80%) and wanting to receive support (79%). Given hypothetical scenarios, most respondents indicated they would likely discuss an error resulting in no harm (77%), minor harm (87%) or major harm (94%). Fifty-seven percent of physicians had tried to serve as a role model by discussing an error and role-modelling was more likely among those who had previously observed an error discussion (OR 4.17, CI 2.34 to 7.42). Conclusions: Most generalist physicians in teaching hospitals report that they usually discuss their errors with colleagues, and more than half have tried to role-model discussions. However, a significant number of these physicians report that they do not usually discuss their errors and some do not know colleagues who would be supportive listeners.

To compare outcomes after aortic valve replacement (AVR) according to valve type specifically in older patients since valve-related risks are age-dependent; two randomised trials comparing mechanical and bioprosthetic valves found better outcomes with mechanical valves, but the samples were small and the patients were considerably younger than most who undergo AVR.Cohort study.1199 US hospitals.Patients 65 years and older undergoing AVR during 1991-2003 (n = 307 054) identified through Medicare claims data.Relative hazard ratios associated with bioprosthetic valves of (1) death (n = 131,719); (2) readmission for haemorrhage (n = 31,186), stroke (n = 25,051) or embolism (n = 5870); (3) reoperation (n = 4216); and (4) death or reoperation (reoperation free survival) in Cox regression analyses adjusting for demographic and clinical factors and hospital-level effects.Overall, 36% of AVR patients received bioprosthetic valves. Bioprosthetic valve recipients were older (77 vs 75 years, p0.001) and generally had higher comorbidity. Bioprosthetic valve recipients had a slightly lower adjusted hazard ratios of death (HR = 0.97; 95% CI 0.95 to 0.98); readmission for haemorrhage, stroke or embolism (HR = 0.90, 95% CI 0.88 to 0.92); and death or reoperation (HR = 0.97, 95% CI 0.96 to 0.98), but a higher hazard ratio of reoperation (HR = 1.25, 95% CI 1.16 to 1.35). However, overall mortality and complication rates were more than 20 and 10 times higher, respectively, than the overall reoperation rate.In older patients undergoing AVR, bioprosthetic valve recipients had slightly lower risks of death and complications, but a higher risk of reoperation. Given the low reoperation rate, these data suggest that bioprosthetic valves may be preferred in older patients.

Nurse staffing is not the same across an entire hospital. Nursing care is delivered in geographically-based units, with wide variation in staffing levels. In particular, staffing in intensive care is much richer than in nonintensive care acute units.To evaluate the association of in-hospital patient mortality with registered nurse staffing and skill mix comparing hospital and unit level analysis using data from the Veterans Health Administration (VHA).A retrospective observational study using administrative data from 129,579 patients from 453 nursing units (171 ICU and 282 non-ICU) in 123 VHA hospitals.We used hierarchical multilevel regression models to adjust for patient, unit, and hospital characteristics, stratifying by whether or not patients had an ICU stay during admission.In-hospital mortality.: Of the 129,579 patients, mortality was 2.9% overall: 6.7% for patients with an ICU stay compared with 1.6% for those without. Whether the analysis was done at the hospital or unit level affected findings. RN staffing was not significantly associated with in-hospital mortality for patients with an ICU stay (OR, 1.02; 95% CI, 0.99-1.03). For non-ICU patients, increased RN staffing was significantly associated with decreased mortality risk (OR, 0.91; 95% CI, 0.86-0.96). RN education was not significantly associated with mortality.Our findings suggest that the association between RN staffing and skill mix and in-hospital patient mortality depends on whether the analysis is conducted at the hospital or unit level. Variable staffing on non-ICU units may significantly contribute to in-hospital mortality risk.

Objective This study compared differences in nurse and patient communication profiles between two telehealth modes: telephone and videophone, and evaluated longitudinal changes in communication, nurse perceptions, and patient satisfaction. Methods Subjects were enrolled in a randomized controlled clinical trial evaluating a 90-day home-based intervention for heart failure. Telephone (n = 14) and videophone (n = 14) interactions were audio taped and analyzed using the Roter Interaction Analysis System. Results Nurses were more likely to use open-ended questions, back-channel responses, friendly jokes, and checks for understanding on the telephone compared to videophone. Compliments given and partnership were more common on the videophone. Patients were more likely to give lifestyle information and approval comments on the telephone, and used more closed-ended questions on the videophone. Nurses perceptions of the interactions were not different between the telephone and videophone, nor did their perceptions change significantly over the course of the intervention. There were no significant differences in patient satisfaction between the telephone and videophone. Conclusions The results of this study did not support use of a videophone over the telephone. Practice implications It is critical to match technologies to patient needs and use the least complex technology possible. When considering use a videophone, health care providers should critically examine the trade-offs between additional complexities with the added value of the visual interaction.

We identified 4-year (2 years before and 2 years after the index [baseline] interview) ED use patterns in older adults and the factors associated with them.A secondary analysis of baseline interview data from the nationally representative Survey on Assets and Health Dynamics Among the Oldest Old linked to Medicare claims data. Participants were 4310 self-respondents 70 years old or older. Current Procedural Terminology (CPT) codes 99281 and 99282 identified low-intensity use, and CPT codes 99283-99285 identified high-intensity use. Exploratory factor analysis and multivariable multinomial logistic regression were used.The majority (56.6%) of participants had no ED visits during the 4-year period. Just 5.7% had only low-intensity ED use patterns, whereas 28.9% used the ED only for high-intensity visits, and 8.7% had a mixture of low-intensity and high-intensity use. Participants with lower immediate word recall scores and those who did not live in major metropolitan areas were more likely to be low-intensity-only ED users. Older individuals, those who did not live in rural counties, had greater morbidity and functional status burdens, and lower immediate word recall scores were more likely to be high-intensity-only ED users. Participants who were older, did not live in major cities, had lower education levels, had greater morbidity and functional status burdens, and lower immediate word recall scores were more likely to have mixed ED use patterns.Nearly half of these older adults used the ED at least once over a 4-year period, with a mean annual ED use percentage of 18.4. Few, however, used the ED only for visits that may have been avoidable. This finding suggests that triaging Medicare patients would not decrease ED overcrowding, although continued surveillance is necessary to detect potential changes in ED use patterns among older adults.