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Early studies of Medicare Shared Savings Program (MSSP) accountable care organizations (ACOs) suggested that physician leadership was an important driver of ACO success, but it is unknown whether the demographic and professional composition of current MSSP ACO governing boards is associated with ACOs’ publicly reported outcomes. To investigate whether governing boards with higher physician participation and greater female involvement have better outcomes. Cross-sectional observational study. All 2017 MSSP ACOs identified by the Center for Medicare and Medicaid Services ACO Public Use Files (PUF). We collected governing board composition from ACO websites in 2019. Outcome metrics included risk-standardized readmission and unplanned admissions rates. We used descriptive statistics and linear regression models to examine the association between board composition and outcomes. Of the 339 ACOs that still existed in 2019 and had available data, 77% had physician-majority boards and 11.5% had no women on their boards. Eighty-nine percent reported a Medicare beneficiary on their board, of which about one-third had a woman representative. The average number of members on MSSP ACO boards was 12, with a mean of 67% physicians and 24% women. Board composition varied minimally by ACO characteristics, such as geographic region, number of beneficiaries, or type of participants. Higher levels of physician participation in ACO governing boards were associated with lower all-cause unplanned admission rates for patients with heart failure (p = − 0.26, p < 0.001) and for patients with multiple chronic conditions (p = − 0.28, p = 0.001). The number of women on the board was not associated with any outcome differences. MSSP ACO governing boards were predominately male and physician-led. Physician involvement may be important for achieving quality goals, while lack of female involvement showcases an opportunity to diversify boards.

Pulmonary rehabilitation (PR) after a hospitalization for COPD is recommended by guidelines, however few patients participate and rates vary between hospitals.To identify contextual factors and strategies that may promote participation in PR following hospitalization for COPD.Using a positive-deviance approach, we calculated hospital-specific rates of PR after hospitalization for COPD among a cohort of Medicare beneficiaries. At a purposive sample of high-performing and innovative hospitals in the United States we conducted in-depth interviews with key stakeholders. We defined high-performing hospitals as having a PR rate above the 95th Percentile, ≥ 6.58%. To learn from hospitals that demonstrated a commitment to improving rates of PR, regardless of post-discharge PR rates, we identified innovative hospitals based on a review of American Thoracic Society conference research presentations from prior years. Interviews were audio-recorded and transcribed verbatim. Using a directed content analysis approach, transcripts were coded iteratively to identify themes.Interviews were conducted with 38 stakeholders at 9 hospitals (7 high-performers and 2 innovators). Hospitals were diverse regarding size, teaching status, PR program characteristics, and geographic location. Participants included PR Medical Directors, PR managers, respiratory therapists, inpatient and outpatient providers and others. We found that high-performing hospitals were broadly focused on improving care for patients with COPD, and several had recently implemented new initiatives to reduce rehospitalizations after an admission for COPD in response to CMS/Medicare's Hospital Readmission Reduction Program. Innovative and high-performing hospitals had systems in place to identify patients with COPD that enabled them to provide patient education and targeted discharge planning. Strategies took several forms, including the use of a COPD navigator or educator. In addition, we found that high-performing hospitals reported effective interprofessional and patient communication, had clinical champions or external change agents, and received support from hospital leadership. Specific strategies to promote PR included education of referring providers, education of patients to increase awareness of PR and its benefits, and direct assistance overcoming barriers.Our findings suggest that successful efforts to increase participation in PR may be most effective when part of larger strategy to improve outcomes for patients with COPD. Further research is necessary to test the generalizability of our findings.

Background Poor sleep is associated with adverse outcomes among postpartum women. Exercise may improve sleep, but this has not been well examined in the postpartum period. Purpose To examine the impact of a culturally modified, individually tailored lifestyle intervention on sleep outcomes among postpartum Latina women. Methods Estudio PARTO was a randomized controlled trial aimed at reducing Type 2 diabetes among Latina women with abnormal glucose tolerance in pregnancy. Participants were randomized to a lifestyle (i.e., diet and exercise; n = 70) or a health and wellness control intervention (n = 78) in late pregnancy (baseline). The Pittsburgh Sleep Quality Index (PSQI) was used to measure sleep quality (PSQI score), onset latency (minutes per night), duration (hours per night), efficiency (percentage of the time in bed asleep), and daytime dysfunction at baseline, 6 weeks, 6 months, and 12 months postpartum. Results Mean PSQI score (6.56 ± 3.87), sleep duration (6.84 ± 1.75 hr/night), and sleep efficiency (79.70% ± 18.10%) did not differ between the arms at baseline. Mixed-effects models indicated a greater decrease of 1.29 in PSQI score (i.e., improved sleep quality) in the lifestyle versus health and wellness arm (95% confidence interval [CI] = −2.50 to −0.08, p = .04) over follow-up. There was the suggestion of a smaller decrease in sleep duration (mean = 0.48 hr/night, 95% CI = −0.10 to 1.06, p = .10) in the lifestyle versus health and wellness arm. There were no statistically significant differences in other sleep outcomes between arms. Conclusions Findings suggest that lifestyle interventions improve sleep quality but not sleep duration, sleep onset latency, sleep efficiency, or daytime dysfunction in postpartum Latina women and, therefore, may hold promise for improving subsequent mental and physical health in this population. Clinical Trials Registration NCT01679210.

Objective While guidelines recommend outpatient management of patients with low-risk pulmonary embolism (PE), little is known about the disposition of patients with PE diagnosed in United States emergency departments (EDs). We sought to determine disposition practices and subsequent health care utilization in patients with acute PE in U.S. EDs. Methods This was a retrospective cohort study of adult ED patients with a new diagnosis of acute PE treated at 740 U.S. acute care hospitals from July 1, 2016, through June 30, 2018. The primary outcome was the initial disposition following an ED visit for acute PE. Additional measures included hospital cost and 30-day revisit rate to the ED. Results A total of 61,070 cases were included in the overall cohort, of which 4.1% of new cases of PE were discharged from the ED. The median hospital-specific proportion of patients discharged was 3.1% (interquartile range = 0.8%-6.8%). The median odds ratio, representing the importance of the hospital in initial disposition decisions, was 2.21 (95% confidence interval = 2.05 to 2.37), which was greater than any patient-level factor with the exception of concurrent ED diagnosis of hypoxemia/respiratory failure, shock, or hypotension. Within 30 days of discharge, 17.9% of discharged cases had an ED return visit to the ED only and 10.3% of patients were hospitalized. Of the 30-day ED return visits in patients initially managed as outpatients, 1.3% had a bleeding-associated diagnosis. Conclusion Despite guidelines promoting outpatient management, few patients are currently discharged home in the United States; however, practice varies widely across hospitals. Return visit rates were high but most did not result in hospitalization.

BackgroundAntibiotic resistance represents a worldwide public health threat. Characterising prescribing patterns for conditions for which antibiotics have no role can inform antimicrobial stewardship efforts. Asthma is among the most common non-infectious diseases in children and results in 100 000 hospitalisations annually in the USA. We sought to identify the rate of antibiotic prescribing in children hospitalised for asthma exacerbations, and to characterise patient and hospital factors associated with receipt of antibiotics.MethodsChildren and adolescents aged 2–17 years admitted to hospital between 1 October 2015 and 30 June 2018 with an asthma exacerbation were identified from the Premier Alliance Database. After excluding hospitalisations for which antibiotics appeared to have been justified, we assessed receipt and duration of antibiotic treatments during the hospital stay. We developed a hierarchical logistic regression model to identify patient and hospital factors associated with antibiotic treatment. For each hospital with at least 10 asthma cases we computed the percentage of cases receiving antibiotic treatment.Results23 129 hospital stays met inclusion criteria; in 3329 (14%) of these, antibiotics were prescribed without clear indication. Hospital prescribing rates varied widely (range 0%–95%), with 25% of hospitals prescribing antibiotics at a rate of 27.5% or more. Patient factors most strongly associated with receipt of antibiotics included the presence of a complex chronic condition (OR: 2.4, 95% CI 2.1 to 2.9; pConclusionsThese findings illustrate an opportunity to reduce unnecessary exposure to antibiotics in children hospitalised with asthma, particularly in general hospitals where three-quarters of children in the USA receive their hospital-based care.

Background There are concerns that starting nicotine replacement therapy (NRT) in the immediate perioperative period may negatively impact wound healing. We investigated the association of NRT with postoperative outcomes among smokers hospitalized for a surgical procedure. Methods This was a retrospective study in 552 hospitals of active smokers hospitalized between January 1, 2015 and December 31, 2016 for a major surgical procedure (Medicare Severity Diagnosis-Related Group expected length of stay, ≥ 2 days). We analyzed the association of receipt of NRT within 2 days of admission with a composite outcome of inpatient complications and with other outcomes. We developed a propensity score for receipt of NRT and examined differences in outcomes in a propensity-matched cohort. Results Of 147,506 active smokers, 25,651 (17.4%) were prescribed NRT within 2 days of admission. Patients treated with NRT were younger; less likely to be black or Hispanic; more likely to have Medicaid; and more likely to have a diagnosis of alcohol or other substance use disorder, or COPD, compared with those who were not treated. In the propensity-matched analysis, there was no association between receipt of NRT and in-hospital complications (OR, 0.99; 95% CI, 0.93-1.05), mortality (OR, 0.84; 95% CI, 0.68-1.04), all-cause 30-day readmissions (OR, 1.02; 95% CI, 0.97-1.07), or 30-day readmission for wound complications (OR, 0.96; 95% CI, 0.86-1.07). Conclusions This is the first large observational study of surgical patients to demonstrate that perioperative NRT is not associated with adverse outcomes after surgery. These results strengthen the evidence that NRT should be prescribed routinely in the perioperative period.

Guidelines recommend pulmonary rehabilitation (PR) after hospitalization for an exacerbation of COPD, but few patients enroll in PR. We explored whether density of PR programs explained regional variation and racial disparities in receipt of PR.We used Centers for MedicareMedicaid Services data from 223,832 Medicare beneficiaries hospitalized for COPD during 2012 who were eligible for PR postdischarge. We used Hospital-Referral Regions (HRR) as the unit of analysis. For each HRR, we calculated the density of PR programs as a measure of program access and estimated risk-standardized rates of PR within 6 months of discharge overall, and for non-Hispanic, white, and black beneficiaries. We used linear regression to examine the relationship between access to PR and HRR PR rates. We tested for racial disparity in PR rates among non-Hispanic white and black beneficiaries living in the same HRRs.Across 306 HRRs, the median number of PR programs per 1,000 Medicare beneficiaries was 0.06 (interquartile range [IQR], 0.04-0.10). Risk-standardized rates of PR ranged from 0.53% to 6.67% (median, 1.93%). Density of PR programs was positively associated with PR rates overall and among non-Hispanic white beneficiaries (P .001), but this relationship was not observed among black beneficiaries. Rates were higher among non-Hispanic white beneficiaries (median, 2.08%; IQR, 1.54%-2.87%) compared with black beneficiaries (median, 1.19%; IQR, 1.15%-1.20%).Greater PR program density was associated with higher rates of PR for non-Hispanic white but not black beneficiaries. Further research is needed to identify reasons for this discrepancy and strategies to increase receipt of PR for black patients.

Objective Performance on pediatric quality measures varies across primary care practices. Health care quality is associated with organizational factors, but their effect is understudied in pediatric care. This study aimed to develop hypotheses regarding the relationship between organizational factors and composite scores on pediatric quality measures. Methods Using a positive deviance approach, semistructured interviews were conducted with pediatricians and staff (N = 35) at 10 purposively selected high-performing pediatric primary care practices in Massachusetts between September and December 2016. Practices were sampled to achieve diversity in geographic location, size, and organizational structure. Interviews aimed to identify organizational strategies (eg, care processes) and contextual factors (eg, teamwork) that may be associated with performance on quality measures. Interviews were audiotaped, transcribed, and analyzed using qualitative content analytic methods. Results We identified 4 major themes (MTs): MT1, Practice Culture; MT2, Practice Structures and Quality Improvement Tools; MT3, Attitudes and Beliefs Related to Measuring Care Quality; and MT4, Perceived Barriers to Achieving High Performance on Quality Measures. MT1 subthemes included contextual factors such as teamwork, leadership, and feeling respected as an employee. MT2 subthemes included fixed characteristics such as practice size and strategies such as the use of an electronic medical record. MT3 and MT4 subthemes linked these constructs to factors external to the practices. Conclusions This study suggested that elements of organizational culture may play as important a role in the quality of care delivered as specific quality improvement strategies. Interventions to further test this relationship may aid practices seeking to improve the care they deliver.

Background There is strong evidence that noninvasive ventilation (NIV) improves the outcomes of patients hospitalized with severe COPD exacerbation, and NIV is recommended as the first-line therapy for these patients. Yet, several studies have demonstrated substantial variation in NIV use across hospitals, leading to preventable morbidity and mortality. In addition, prior studies suggested that efforts to increase NIV use in COPD need to account for the complex and interdisciplinary nature of NIV delivery and the need for team coordination. Therefore, our initial project aimed to compare two educational strategies: online education (OLE) and interprofessional education (IPE), which targets complex team-based care in NIV delivery. Due to the impact of the COVID-19 pandemic on recruitment and planned intervention, we had made several changes in the study design, statistical analysis, and implementation strategies delivery as outlined in the methods. Methods We originally proposed a two-arm, pragmatic, cluster, randomized hybrid implementation-effectiveness trial comparing two education strategies to improve NIV uptake in patients with severe COPD exacerbation in 20 hospitals with a low baseline rate of NIV use. Due to logistical constrains and slow recruitment, we changed the study design to an opened cohort stepped-wedge design with three steps which will allow the institutions to enroll when they are ready to participate. Only the IPE strategy will be implemented, and the education will be provided in an online virtual format. Our primary outcome will be the hospital-level risk-standardized NIV proportion for the period post-IPE training, along with the change in rate from the period prior to training. Aim 1 will compare the change over time of NIV use among patients with COPD in the step-wedged design. Aim 2 will explore the mediators’ role (respiratory therapist autonomy and team functionality) on the relationship between the implementation strategies and effectiveness. Finally, in Aim 3, through interviews with providers, we will assess the acceptability and feasibility of the educational training. Conclusion The changes in study design will result in several limitation. Most importantly, the hospitals in the three cohorts are not randomized as they enroll based on their readiness. Second, the delivery of the IPE is virtual, and it is not known if remote education is conducive to team building. However, this study will be among the first to test the impact of IPE in the inpatient setting carefully and may generalize to other interventions directed to seriously ill patients. Trial registration ClinicalTrials.govNCT04206735. Registered on December 20, 2019

Rationale: Although clinical trials have found that pulmonary rehabilitation (PR) can reduce the risk of readmissions after hospitalization for a chronic obstructive pulmonary disease (COPD) exacer...

BACKGROUND: Opioids are a leading cause of adverse drug events in the hospital. Guidelines recommend that physicians assess the risks of opioids and discuss them with patients when considering opioid use. There are no studies examining patient- and prescribing-related risk factors for opioid-related adverse drug events (ORADEs) in hospitalized medical patients. OBJECTIVE: To identify independent risk factors for severe ORADEs in hospitalized medical patients. DESIGN: Retrospective cohort study. PATIENTS: Medical patients hospitalized at US, non-federal, and acute care facilities, with at least one pharmacy charge for an opioid during hospitalization. We excluded patients with metastatic malignancy, hospice, or palliative care billing codes. MAIN MEASURES: We used Cox proportional hazards modeling to identify risk factors for severe ORADEs, defined by a pharmacy charge for naloxone. Candidate risk factors were chosen a priori, based on clinical grounds and prior literature. KEY RESULTS: Among 731,208 hospitalizations (median age 60, 56.5% female), a severe ORADE occurred in 2727 (0.4%). Independent risk factors included patient characteristics (advanced age, female gender), comorbidities (congestive heart failure, opioid abuse/dependence, non-opioid drug abuse/dependence, psychosis, depression, obstructive sleep apnea), organ failures on admission (respiratory failure, shock/hypotension, renal failure, hepatic failure, acidosis, and neurologic failure), medication co-administrations (antipsychotics and short-acting benzodiazepines), and characteristics of the opioid prescriptions themselves (total dose for the day, parenteral route of administration, and receipt of multiple types of opioids in a day). Although a risk prediction model derived from these factors performed well on stratified k-fold cross-validation (average c-statistics 0.68–0.71), the low incidence of the outcome limited the positive predictive value of the risk score. CONCLUSIONS: In this national cohort of medical patients, we identified several risk factors for ORADEs that can be used to inform physician decision-making, conversations with patients about risk, and development and targeting of harm reduction strategies for at-risk populations. ELECTRONIC SUPPLEMENTARY MATERIAL: The online version of this article (10.1007/s11606-019-05490-w) contains supplementary material, which is available to authorized users.

BACKGROUND: In patients hospitalized with heart failure (HF) exacerbations, physicians routinely supplement potassium to maintain levels ≥4.0 mEq/L. The evidence basis for this practice is relatively weak. We aimed to evaluate the association between serum potassium levels and outcomes in patients hospitalized with HF. METHODS: We identified patients admitted with acute HF exacerbations to hospitals that contributed to an electronic health record-derived dataset. In a subset of patients with normal admission serum potassium (3.5-5.0 mEq/L), we averaged serum potassium values during a 72-hour exposure window and categorized as follows: 4.5 mEq/L (high normal). We created multivariable models examining associations between these categories and outcomes. RESULTS: We included 4,995 patients: 2,080 (41.6%), 2,326 (46.6%), and 589 (11.8%) in the 4.5 mEq/L cohorts, respectively. After adjustment for demographics, comorbidities, and presenting severity, we observed no difference in outcomes between the low and medium normal groups. Compared to patients with levels 4.5 mEq/L had a longer length of stay (median of 0.6 days; 95% CI = 0.1 to 1.0) but did not have statistically significant increases in mortality (OR [odds ratio] = 1.51; 95% CI = 0.97 to 2.36) or transfers to the intensive care unit (OR = 1.78; 95% CI = 0.98 to 3.26). CONCLUSIONS: Inpatients with heart failure who had mean serum potassium levels of 4.5 may be associated with increased risk of poor outcomes.

BACKGROUND: Latinas experience high levels of stress in pregnancy, however few studies have investigated how acculturation affects pregnancy mental health among Latinas. The goal of this study was to determine if acculturation was associated with pregnancy stress among pregnant, predominantly Puerto Rican women. METHODS: Participants (n=1426) were enrolled in Proyecto Buena Salud, a prospective cohort study of Latinas. Acculturation on a bi-dimensional scale that allows for identification with both Latina and continental US cultures (i.e., bi-cultural vs. high or low acculturation) was measured in early pregnancy via the Psychological Acculturation Scale (PAS), language preference, and generation in the US. Stress was measured in early and mid/late pregnancy using Cohen’s 14-item Perceived Stress Scale. RESULTS: After adjustment for risk factors, women with bicultural acculturation had significantly lower stress in overall pregnancy (β = −2.15, 95% CI −3.5, −0.81) and in mid/late pregnancy (β = −2.35, 95% CI −3.92, −0.77) as compared to women with low acculturation. There were no significant associations between proxies of acculturation (i.e., language preference and generation) and stress. CONCLUSIONS: Bicultural psychological acculturation was associated with lower stress in pregnancy, while proxies of acculturation were not. Bi-dimensional measures of psychological acculturation should be considered in future studies of maternal mental health.

Background Pediatric health care quality in the United States varies, but the reasons for variation are not fully understood. Differences in pediatric practices' organizational characteristics, such as organizational structures, strategies employed to improve quality, and other contextual factors, may contribute to the variation observed. Purpose To assess the relationship between organizational characteristics and performance on clinical quality (CQ) and patient experience (PE) measures in primary care pediatric practices in Massachusetts. Methodology A 60-item questionnaire that assessed the presence of selected organizational characteristics was sent to 172 pediatric practice managers in Massachusetts between December 2017 and February 2018. The associations between select organizational characteristics and publicly available CQ and PE scores were analyzed using analysis of variance; open-ended survey questions were analyzed using qualitative content analysis. Results Eighty-six practices (50.0%) responded; 80 (46.5%) were included in the primary analysis. Having a quality champion (p = .03), offering co-located specialty services (e.g., behavioral health; p = .04), being a privately owned practice (p = .04), believing that patients and families feel respected (p = .03), and having a lower percentage of patients (10%-25%) covered by public health insurance (p = .04) were associated with higher CQ scores. Higher PE scores were associated with private practice ownership (p = .0006). Qualitative analysis suggested organizational culture and external factors, such as health care finance, may affect quality. Conclusions Both modifiable organizational practices and factors external to a practice may affect quality of care. Addressing differences in practice performance may not be reducible to implementation of changes in single organizational characteristics. Practice implications Pediatric practices seeking to improve quality of care may wish to adopt the strategies that were associated with higher performance on quality measures, but additional studies are needed to better understand the mechanisms behind these associations and how they relate to each other.

Rationale: Current guidelines recommend pulmonary rehabilitation (PR) after hospitalization for a chronic obstructive pulmonary disease (COPD) exacerbation, but little is known about its adoption or factors associated with participation. Objectives: To evaluate receipt of PR after a hospitalization for COPD exacerbation among Medicare beneficiaries and identify individual- and hospital-level predictors of PR receipt and adherence. Methods: We identified individuals hospitalized for COPD during 2012 and recorded receipt, timing, and number of PR visits. We used generalized estimating equation models to identify factors associated with initiation of PR within 6 months of discharge and examined factors associated with number of PR sessions completed. Results: Of 223,832 individuals hospitalized for COPD, 4,225 (1.9%) received PR within 6 months of their index hospitalization, and 6,111 (2.7%) did so within 12 months. Median time from discharge until first PR session was 95 days (interquartile range, 44–190 d), and median number of sessions completed was 16 (interquartile range, 6–25). The strongest factor associated with initiating PR within 6 months was prior home oxygen use (odds ratio [OR], 1.49; 95% confidence interval [CI], 1.39–1.59). Individuals aged 75–84 years and those aged 85 years and older (respectively, OR, 0.70; 95% CI, 0.66–0.75; and OR, 0.25; 95% CI 0.22–0.28), those living over 10 miles from a PR facility (OR, 0.42; 95% CI, 0.39–0.46), and those with lower socioeconomic status (OR, 0.42; 95% CI, 0.38–0.46) were less likely to receive PR. Conclusions: Two years after Medicare began providing coverage for PR, participation rates after hospitalization were extremely low. This highlights the need for strategies to increase participation.

AIM: Publicly reported quality data theoretically enable parents to choose higher-performing paediatric practices. However, little is known about how parents decide where to seek paediatric care. We explored the relationship between geographic factors, care quality and choice of practice to see if the decision-making process could be described in terms of a ‘gravity model’ of spatial data. METHODS: In the context of a randomised controlled trial, we used a geographic information system to calculate flow volume between practice locations and participants’ homes, to locate subjects within a census tract, to determine distances between points and to perform exploratory mapping. Generalised linear modelling was then used to determine whether the data fit a gravity model, which is a spatial model that evaluates factors impacting travel from one set of locations to another. RESULTS: A total of 662 women and 52 paediatric practices were included in the analysis. Proximity of a practice to home was the most important factor in choosing a practice (Z = −15.01, P < 0.001). Practice size was important to a lesser extent, with larger practices more likely to be chosen (Z = 8.96, P < 0.001). A practice’s performance on quality measures was associated with choice only for women who had received an intervention to increase use of quality data (Z = 2.51, P < 0.05). CONCLUSIONS: The gravity model and the concept of flow can help explain the choice of paediatric practice in a predominantly low-income, racially ethnic minority (non-White) urban population. This has important ramifications for the potential impact of publicly reported quality data.

INTRODUCTION: This study assesses the impact of a culturally modified, motivationally targeted, individually tailored intervention on postpartum weight retention among Hispanic women with abnormal glucose tolerance during pregnancy. METHODS: Estudio PARTO (Project Aiming to Reduce Type twO diabetes) was an RCT conducted in Western Massachusetts (collected 2013–2017, analyzed 2018–2020). Hispanic women with blood glucose ≥140 mg/dL (7.77 mmol/L) on routine nonfasting oral glucose challenge test were randomized to a Lifestyle Intervention (n=100) focusing on healthy exercise and diet or to a comparison Health and Wellness (n=104) Intervention with no mention of exercise or diet behavior changes. The primary outcome was change in weight, calculated as the difference between prepregnancy weight and 6-week, 6-month, and 12-month postpartum weight. The secondary outcome was achievement of weight reduction to prepregnancy weight if prepregnancy BMI was normal, or a 5% reduction if prepregnancy BMI was overweight/obese. RESULTS: In intent-to-treat analyses, there were no significant differences in weight change pattern between the intervention arms across all follow-up timepoints (β=0.03, 95% CI= −3.38, 3.45). However, at 12 months postpartum, women in the Lifestyle Intervention arm had a statistically significant 2.5-fold higher odds of meeting the secondary weight reduction outcome (OR=2.52, 95% CI=1.09, 5.82) as compared with women in the Health and Wellness arm. Regardless of intervention arm, women who reported higher levels of postpartum sports/exercise had a greater decrease in weight (β= −2.39, 95% CI −4.66, −0.13, p=0.04) compared with women reporting lower levels. CONCLUSIONS: In this randomized trial among Hispanic women, no significant overall differences in weight change pattern between intervention arms were observed. Higher levels of self-reported physical activity were associated with greater weight loss in both arms. TRIAL REGISTRATION: This study is registered at www.clinicaltrials.gov NCT01679210.

Background: Short interpregnancy interval (IPI) is associated with risk of adverse pregnancy outcomes; however, few studies have evaluated the role of depression as a risk factor for short IPI. Puerto Rican women in the United States experience disparities in adverse birth outcomes and have the highest birth rates. Methods: We analyzed the association between prenatal depressive symptoms and IPI in Proyecto Buena Salud, a prospective cohort of predominantly Puerto Rican women in Western Massachusetts (2006–2011). Depression was measured using the Edinburgh Postnatal Depression Scale (EPDS) in early, mid, and late pregnancy. We calculated follow-up time as the difference between the date of delivery of the index pregnancy and the last menstrual period of the subsequent pregnancy using medical records and billing data. We defined short IPI as ≤18 months. Results: Of 1262 eligible women, 35% (n = 440) had at least probable minor depression (EPDS scores ≥13) and 25% (n = 315) had probable major depression (EPDS scores ≥15). Participants were followed for a median of 3.7 years (interquartile range = 1.4–6.0 years) and 240 (20.6%) participants experienced a short IPI. After adjusting for risk factors, women with probable minor depression (adjusted odds ratio [aOR] = 1.39, 95% confidence interval [CI] = 1.02–1.88) and probable major depression (aOR = 1.42, 95% CI = 1.02–1.97) during pregnancy had increased odds of short IPI. Conclusions: Prenatal depressive symptoms were common in this Puerto Rican population and were associated with a modest increase in odds of short IPI. Further examination of the pathways through which mental health may affect IPI in vulnerable populations is warranted.

Both inflammation and smoking are independent predictors of morbidity and mortality among people living with HIV (PLHIV). As smoking burden is likely to exacerbate inflammation, we tested the hypothesis that higher intensity and longer duration of smoking are positively associated with C-reactive protein (CRP, an inflammatory marker) among 284 PLHIV in Kathmandu, Nepal. We measured smoking status, intensity of smoking, smoking duration, and CRP concentrations. In total, 22.9% of never smokers, 24.3% former smokers, and 34.1% current smokers had high CRP (> 3 mg/l). The median intensity and duration of smoking were 12 (cigarettes/day) and 19 years, respectively. Intensity of smoking (beta for increase in number of cigarettes/day: β = 0.245; p = 0.017), smoking duration (beta for 1-year increase in smoking: β = 0.341; p = 0.013), and pack-years of smoking (beta for 1-pack-years of smoking increase: β = 0.351; p = 0.002) were each positively associated with CRP concentrations. While quitting is important, reducing the intensity and duration of smoking until quitting might be helpful in reducing the levels of inflammation, thereby in mitigating HIV-related harms.

Rationale: Patients undergoing cardiac surgery often require vasopressor or inotropic (“vasoactive”) medications, but patterns of postoperative use are not well described. Objectives: This study aimed to describe vasoactive medication administration throughout hospitalization for cardiac surgery, to identify patient- and hospital-level factors associated with postoperative use, and to quantify variation in treatment patterns among hospitals. Methods: Retrospective study using the Premier Healthcare Database. The cohort included adult patients who underwent coronary artery bypass grafting or open valve repair or replacement (or in combination) from January 1, 2016, to June 30, 2018. Primary outcome was receipt of vasoactive medication(s) on the first postoperative day (POD1). We identified patient- and hospital-level factors associated with receipt of vasoactive medications using multilevel mixed-effects logistic regression modeling. We calculated adjusted median odds ratios to determine the extent to which receipt of vasoactive medications on POD1 was determined by each hospital, then calculated quotients of Akaike Information Criteria to compare the relative contributions of patient and hospital characteristics and individual hospitals with observed variation. Results: Among 104,963 adults in 294 hospitals, 95,992 (92.2%) received vasoactive medication(s) during hospitalization; 30,851 (29.7%) received treatment on POD1, most commonly norepinephrine (n = 11,427, 37.0%). A median of 29.0% (range, 0.0–94.4%) of patients in each hospital received vasoactive drug(s) on POD1. After adjustment, hospital of admission was associated with twofold increased odds of receipt of any vasoactive medication on POD1 (adjusted median odds ratio, 2.07; 95% confidence interval, 1.93–2.21). Admitting hospital contributed more to observed variation in POD1 vasoactive medication use than patient or hospital characteristics (quotients of Akaike Information Criteria 0.58, 0.44, and

Objective This study aimed to evaluate the association between prepregnancy body mass index (BMI), gestational weight gain (GWG), and cesarean delivery in Hispanics. Methods We examined these associations among 1,215 participants in Proyecto Buena Salud, a prospective cohort of Hispanic women studied from 2006 to 2011. Prepregnancy BMI, GWG, and the mode of delivery were abstracted from medical records. Results A quarter of the participants entered pregnancy with obesity, 23% delivered via cesarean, and 52% exceeded the Institute of Medicine guidelines for GWG. After adjusting for age, women with obesity had 2.03 times the odds of cesarean delivery compared with women with normal BMI (95% confidence interval [CI]: 1.46-2.82); findings remained significant after adjusting for GWG. Women with excessive total GWG had 1.49 times the odds of cesarean delivery (95% CI: 1.06-2.10) compared with women who gained within guidelines. An excessive rate of third trimester GWG (standard deviation [SD] change in GWG per week) increased the odds of cesarean delivery (odds ratio = 1.66; 95% CI: 1.05-2.62), while an excessive rate of first and third trimester GWG was not associated with increased odds. Conclusions Obesity prior to pregnancy was associated with increased odds of cesarean delivery among Hispanics. Excessive GWG across pregnancy and an excessive rate of third trimester GWG were also associated with increased odds.

To determine the relationship between hospital noninvasive ventilation caseload and outcomes among patients with an acute chronic obstructive pulmonary disease exacerbation.Cross-sectional study of 13,893 patients with chronic obstructive pulmonary disease treated with noninvasive ventilation.A total of 243 U.S. hospitals participating in the Premier Inpatient Database.A total of 13,893 patients admitted between July 2009 and June 2011.None.Annual hospital volume of noninvasive ventilation was analyzed as a continuous variable, as well as after grouping it in four categories. The median hospital annual volume of noninvasive ventilation use was 627 and varied from 234 admissions in quartile 1 to 1,529 admissions in quartile 4. Noninvasive ventilation failure occurred in 15.2%, and in-hospital mortality was 6.5%. After adjusting for patient characteristics, relative to low-volume hospitals, high-volume hospitals did not have lower noninvasive ventilation failure (odds ratio quartile 4 vs quartile 1, 1.05; 95% CI, 0.65-1.68) or in-hospital mortality (odds ratio quartile 4 vs quartile 1, 0.88; 95% CI, 0.69-1.12). In a hierarchical multivariable analysis with adjustment for patient characteristics where volume was assessed as a continuous variable, hospital volume was not related to outcomes, including noninvasive ventilation failure (p = 0.87), in-hospital mortality (p = 0.88), 30-day readmission for chronic obstructive pulmonary disease (p = 0.83), or hospital length of stay (p = 0.12).The results of this large retrospective cohort study suggest that hospitals with higher noninvasive ventilation volume do not achieve better outcomes of patients with chronic obstructive pulmonary disease exacerbation treated with noninvasive ventilation; even hospitals with low noninvasive ventilation volume are able to successfully implement this intervention.

Objectives To examine associations between depression and preterm birth and small-for gestational age (SGA) among women of predominantly Puerto Rican descent, a population who experiences disparities in adverse birth outcomes and one of the highest infant mortality rates in the United States. Methods Proyecto Buena Salud (PBS) was a prospective cohort study conducted from 2006 to 2011 at a large tertiary care center in Western Massachusetts. Caribbean Islander (i.e., Puerto Rican and Dominican Republic) women were interviewed in early, mid and late pregnancy. Among 1262 participants, associations between depression, assessed using the Edinburgh Postnatal Depression Scale, and risk of preterm birth and small-for-gestational age (SGA) were evaluated. Results Women with at least probable minor depression [odds ratio (OR) = 1.77 (95% confidence interval (CI) = 1.02, 3.07)] or probable major depression [OR = 1.82 (95% CI = 1.01, 3.25)] in mid-pregnancy had an increased risk of SGA compared to non-depressed women in adjusted analyses. Borderline significant associations were observed between increasing levels of depressive symptom scores in early and mid-pregnancy [OR = 1.05 (95% CI = 1.00, 1.11) and OR = 1.04 (95% CI = 1.00, 1.09), respectively] and each additional trimester of exposure to probable major depression across mid- to late pregnancy [OR = 1.66 (95% CI = 1.00, 2.74)] and SGA. Late pregnancy depression was not associated with SGA; depression during pregnancy was not associated with preterm birth. Conclusions for Practice In this population of predominantly Puerto Rican women, mid-pregnancy depression increased risk for SGA. Findings can inform culturally appropriate, targeted interventions to identify and treat pregnant women with depression.

A recent analysis of the Nationwide Inpatient Sample (NIS) found that inpatient echocardiography was associated with improved survival but was used only infrequently in clinical situations where echocardiography is often indicated.1 One potential limitation of this study was highlighted by an internal validation which showed that rates of echocardiography use were much higher at the author’s hospital than reported in NIS. For example, among patients with myocardial infarction, validation rates were 75% versus 6.3% for the NIS. Given this discrepancy, we sought to determine the accuracy of claims data, such as the NIS, for quantifying echocardiography use. We hypothesized that the International Classification Disease-9 Clinical Modification ( ICD-9 CM ) code for echocardiography (88.72) would show poor sensitivity for echocardiography use, and that actual echocardiography use rates would be higher than reported in NIS. We used the Premier Healthcare Informatics (Charlotte, NC) dataset that includes data on a geographically and structurally diverse group of hospitals from 2014 to assess inpatient echocardiography across 8 broad patient conditions for which echocardiography is commonly ordered. Unlike NIS, which reports only standard demographic data and ICD-9 procedure and …

Background In randomized controlled trials, perioperative administration of amiodarone has been shown to reduce the incidence of postoperative atrial arrhythmias and length of stay ( LOS ) among patients undergoing coronary bypass surgery. However, little is known about the use or effectiveness of perioperative amiodarone in routine clinical practice. Methods and Results We studied patients ≥18 years old without a previous history of atrial or ventricular arrhythmias who underwent elective coronary bypass surgery between 2013 and 2014 within a network of 235 US hospitals. Perioperative amiodarone was defined as receipt of amiodarone either on the day of or the day preceding surgery. We used covariate‐adjusted modeling and instrumental variable methods to examine the association between receipt of amiodarone and the development of atrial arrhythmias, in‐hospital mortality, readmission, LOS , and cost. Of 12 758 patients, 2195 (17.2%) received perioperative amiodarone, 3330 (26.1%) developed atrial arrhythmias postoperatively, and the average LOS was 6.4 days (±2.6 days). Instrumental variable analysis showed that receipt of perioperative amiodarone was associated with lower risk of atrial arrhythmias (risk difference −11 percentage points, 95% CI −19 to −4 percentage points; P =0.002) and a shorter LOS (−0.7 day, 95% CI −1.39 to −0.01 days; P =0.048). There was no association between receipt of perioperative amiodarone and in‐hospital mortality, cost, or readmission. Conclusions Among patients undergoing coronary bypass surgery without previous arrhythmias, perioperative amiodarone is associated with a lower risk of atrial arrhythmias and shorter LOS . These findings are consistent with previous randomized trials and lend support to current guideline recommendations.

Importance Although professional society guidelines discourage use of empirical antibiotics in the treatment of asthma exacerbation, high antibiotic prescribing rates have been recorded in the United States and elsewhere. Objective To determine the association of antibiotic treatment with outcomes among patients hospitalized for asthma and treated with corticosteroids. Design, Setting, and Participants Retrospective cohort study of data of 21 628 adults hospitalized for asthma exacerbation and treated with systemic corticosteroids in 540 US acute care hospitals from January 1, 2015, through December 31, 2016. Exposures Early antibiotic treatment, defined as treatment with an antibiotic initiated during the first 2 days of hospitalization. Patients not treated with antibiotics or treated on day 2 or later were included in the nontreated/late-treated group. Patients with documented infection diagnosed at admission were excluded. Main Outcomes and Measures The primary outcome measure was hospital length of stay. Other outcomes included treatment failure (initiation of mechanical ventilation, transfer to the intensive care unit after hospital day 1, in-hospital mortality, or readmission for asthma within 30 days of discharge), hospital costs, and antibiotic-related diarrhea. Multivariable adjustment, propensity score matching, propensity weighting, and instrumental variable analysis were used to assess the association of antibiotic treatment with outcomes. Results Of the 21 628 patients, the median (interquartile range [IQR]) age was 46 (33-59) years, 15 662 (72.4%) were women and 9616 (44.5%) were White, and Medicare was the primary form of health insurance for 5499 (25.4%). Antibiotics were prescribed for 8927 patients (41.3%) on day 1; 3022 patients (14.0%) were started after day 1. Compared with patients not treated with antibiotics or treated after day 1, patients treated with antibiotics on day 1 were older (median [IQR] age, 48 [35-60] vs 45 [32-57] years), more likely to be White (48.7% vs 41.5%) and smokers (4.5% vs 3.2%), and had a higher number of comorbidities (eg, congestive heart failure, 5.7% vs 5.4%). Those treated with antibiotics on day 1 had a statistically significant longer hospital stay compared with those not treated on day 1 (mean [SD], 2.81 [2.27] vs 2.57 [2.45] days; difference, 0.11 days, 95% CI, 0.03 to 0.19; median [IQR] 2 [1-4] vs 2 [1-3] days). In propensity score–matched analysis, receipt of antibiotics on day 1 was associated with a marginally longer but not clinically meaningful increase in hospital stay (length of stay ratio, 1.06; 95% CI, 1.04 to 1.09), higher cost of hospitalization (median [IQR] cost, $4320 [$2754-$6716] vs $3861 [$2479-$6236]) but lower risk of treatment failure (7.1% vs 8.2%; difference, −1.08%, 95% CI, −1.93% to −0.24%; adjusted OR, 0.86; 95% CI, 0.77 to 0.97). Multivariable adjustment, propensity score weighting, and instrumental variable analysis yielded similar results. Conclusions and Relevance Among adult patients hospitalized for asthma exacerbation and treated with corticosteroids, antibiotic therapy initiated on day 1 of hospitalization was associated with a slightly longer but not clinically important increase in hospital length of stay, higher hospitalization cost, and lower risk of treatment failure. These findings highlight the need to perform randomized clinical trials to determine the role of antibiotic prescribing among patients hospitalized for asthma exacerbation.

As the most common reason for hospitalization among the elderly, admissions for acute heart failure (HF) are a frequent target for quality measurement and improvement activities. Large scale performance improvement initiatives such as the Centers for Medicare and Medicaid Services (CMS) Value Based Purchasing program use hospital HF mortality measures to determine hospital reimbursement rates.(1,2) To identify patients with a hospitalization for HF, programs use International Classification of Diseases 9th or 10th Edition codes limited to the principal diagnosis position. However, studies in other conditions suggest that there may be limitations to an approach that focuses only on a principal diagnosis to identify hospitalizations tracked for performance measurement. For example, diagnostic coding in pneumonia gradually shifted more severe conditions (e.g., sepsis) that were not targeted for outcome measurement into the principal diagnosis position in place of pneumonia. Hospitals that were more likely to shift the most severely ill patients with pneumonia out of performance surveillance (e.g., by using a principal diagnosis of sepsis) showed lower risk adjusted mortality rates than hospitals that were more likely to code pneumonia as a principal diagnosis, biasing hospital pneumonia mortality performance measures.(3–5) Although hospitalizations for acute HF may plausibly also be coded with alternative principal diagnoses (e.g., acute respiratory failure), it is unknown whether the kind of coding trends observed in pneumonia have carried over to HF, or whether shifts to alternative principal diagnoses have biased estimates of HF outcome performance measures. Among patients hospitalized for acute HF, we evaluated trends in the position of HF diagnosis codes and the association between use of alternative principal diagnosis codes and risk-standardized HF mortality rates.

Little is known about the effectiveness of noninvasive ventilation for patients hospitalized with asthma exacerbation.To assess clinical outcomes of noninvasive (NIV) and invasive mechanical ventilation (IMV) and examine predictors for NIV use in patients hospitalized with asthma.This was a retrospective cohort study at 97 U.S. hospitals using an electronic medical record database. We developed a hierarchical regression model to identify factors associated with the choice of initial ventilation and used the Laboratory Acute Physiological Score to adjust for differences in the severity of illness. We assessed the outcomes of patients treated with initial NIV or IMV in a propensity-matched cohort.Among 13,930 subjects, 73% were women and 54% were white. The median age was 53 years. Overall, 1,254 patients (9%) required ventilatory support (NIV or IMV). NIV was the initial ventilation method for 556 patients (4.0%) and IMV for 668 (5.0%). Twenty-six patients (4.7% of patients treated with NIV) had to be intubated (NIV failure). The in-hospital mortality was 0.2, 2.3, 14.5, and 15.4%, and the median length of stay was 2.9, 4.1, 6.7, and 10.9 days among those not ventilated, ventilated with NIV, ventilated with IMV, and with NIV failure, respectively. Older patients were more likely to receive NIV (odds ratio, 1.06 per 5 yr; 95% confidence interval [CI], 1.01-1.11), whereas those with higher acuity (Laboratory Acute Physiological Score per 5 units: odds ratio, 0.85; 95% CI, 0.82-0.88) and those with concomitant pneumonia were less likely to receive NIV. In a propensity-matched sample, NIV was associated with a lower inpatient risk of dying (risk ratio, 0.12; 95% CI, 0.03-0.51) and shorter lengths of stay (4.3 d less; 95% CI, 2.9-5.8) than IMV.Among patients hospitalized with asthma exacerbation and requiring ventilatory support (NIV or IMV), more than 40% received NIV. Although patients successfully treated with NIV appear to have better outcomes than those treated with IMV, the low rate of NIV failure suggests that NIV was being used selectively in a lower risk group. The increased risk of mortality for patients who fail NIV highlights the need for careful monitoring to avoid possible delay in intubation.

BACKGROUND Understanding the severity of patients' dyspnea is critical to avoid under- or overtreatment of patients with acute cardiopulmonary conditions. OBJECTIVE To evaluate the agreement between dyspnea assessment by patients and healthcare providers and to explore which factors contribute to discordance in assessment. DESIGN, SETTINGS AND PARTICIPANTS Prospective study of patients hospitalized for acute cardiopulmonary diseases at an urban teaching hospital. INTERVENTION AND MEASUREMENTS A numerical rating scale (0–10) was used to assess dyspnea severity as perceived by patients and assessed by providers. Agreement was defined as a score within ±1 between patient and healthcare provider; differences of ≥2 points were considered over- or underestimations. The relationship between patient self-perceived dyspnea severity and provider rating was assessed using a weighted kappa coefficient. RESULTS Of the 138 patients enrolled, 33% had a diagnosis of heart failure, 30% chronic obstructive pulmonary disease, and 13% pneumonia; median age was 72 years, and 57% were women. In all, 96 patient-physician and 138 patient-nurses pairs were included in the study. The kappa coefficient for agreement was 0.11 (95% confidence interval [CI]: 0.01 to 0.21) between patients and physicians and 0.18 (95% CI: 0.12 to 0.24) between patients and nurses. Physicians underestimated patients' dyspnea 37.9% of the time and overestimated it 25.8% of the time, whereas nurses underestimated it 43.5% of the time and overestimated it 12.4% of the time. Admitting diagnosis was the only patient factor associated with discordance. CONCLUSIONS Agreement between patient perception of dyspnea and healthcare providers' assessment is low. Future studies should prospectively test whether routine assessment of dyspnea results in better patient outcomes. Journal of Hospital Medicine 2016. © 2016 Society of Hospital Medicine

Objectives To prospectively evaluate the association between gestational weight gain (GWG), prepregnancy body mass index (BMI), and hypertensive disorders of pregnancy using the revised Institute of Medicine (IOM) Guidelines. Methods We examined these associations among 1359 participants in Proyecto Buena Salud, a prospective cohort study conducted from 2006 to 2011 among women from the Caribbean Islands. Information on prepregnancy BMI, GWG, and incident diagnoses of hypertension in pregnancy were based on medical record abstraction. Results Four percent (n = 54) of women were diagnosed with hypertension in pregnancy, including 2.6 % (n = 36) with preeclampsia. As compared to women who gained within IOM GWG guidelines (22.8 %), those who gained above guidelines (52.5 %) had an odds ratio of 3.82 for hypertensive disorders (95 % CI 1.46-10.00; ptrend = 0.003) and an odds ratio of 2.94 for preeclampsia (95 % CI 1.00-8.71, ptrend = 0.03) after adjusting for important risk factors. Each one standard deviation (0.45 lbs/week) increase in rate of GWG was associated with a 1.74 odds of total hypertensive disorders (95 % CI 1.34-2.27) and 1.86 odds of preeclampsia (95 % CI 1.37-2.52). Conclusions for Practice Findings from this prospective study suggest that excessive GWG is associated with hypertension in pregnancy and could be a potentially modifiable risk factor in this high-risk ethnic group.

AimsTo assess the impact of a culturally modified, motivationally targeted, individually-tailored intervention on postpartum physical activity (PA) and PA self-efficacy among Hispanic women.MethodsEstudio PARTO was a randomized controlled trial conducted in Western Massachusetts from 2013-17. Hispanic women who screened positive for gestational diabetes mellitus were randomized to a Lifestyle Intervention (LI, n = 100) or to a comparison Health and Wellness (HW, n = 104) group during late pregnancy. Exercise goals in LI were to meet American College of Obstetrician & Gynecologists guidelines for postpartum PA. The Pregnancy Physical Activity Questionnaire (PPAQ) and the Self-Efficacy for Physical Activity Questionnaire were administered at 6 weeks, 6 months, and 1 year postpartum.ResultsCompared to baseline levels, both groups had significant increases in moderate-to-vigorous PA at 6 months and one year postpartum (i.e., LI: mean change = 30.9 MET-hrs/wk, p = 0.05; HW: 27.6 MET-hrs/wk, p = 0.01), with only LI group experiencing significant increases in vigorous PA (mean change = 1.3 MET-hrs/wk, p = 0.03). Based on an intent-to-treat analysis using mixed effects models, we observed no differences in pattern of change in PA intensity and type over time between intervention groups (all p > 0.10). However, there was the suggestion of a greater decrease in sedentary activity in the LI group compared to the HW group (β = -3.56, p = 0.09).ConclusionsIn this randomized trial among high-risk Hispanic women, both groups benefitted from participation in a postpartum intervention.

Meta-analyses have suggested that initiating pulmonary rehabilitation after an exacerbation of chronic obstructive pulmonary disease (COPD) was associated with improved survival, although the number of patients studied was small and heterogeneity was high. Current guidelines recommend that patients enroll in pulmonary rehabilitation after hospital discharge.To determine the association between the initiation of pulmonary rehabilitation within 90 days of hospital discharge and 1-year survival.This retrospective, inception cohort study used claims data from fee-for-service Medicare beneficiaries hospitalized for COPD in 2014, at 4446 acute care hospitals in the US. The final date of follow-up was December 31, 2015.Initiation of pulmonary rehabilitation within 90 days of hospital discharge.The primary outcome was all-cause mortality at 1 year. Time from discharge to death was modeled using Cox regression with time-varying exposure to pulmonary rehabilitation, adjusting for mortality and for unbalanced characteristics and propensity to initiate pulmonary rehabilitation. Additional analyses evaluated the association between timing of pulmonary rehabilitation and mortality and between number of sessions completed and mortality.Of 197 376 patients (mean age, 76.9 years; 115 690 [58.6%] women), 2721 (1.5%) initiated pulmonary rehabilitation within 90 days of discharge. A total of 38 302 (19.4%) died within 1 year of discharge, including 7.3% of patients who initiated pulmonary rehabilitation within 90 days and 19.6% of patients who initiated pulmonary rehabilitation after 90 days or not at all. Initiation within 90 days was significantly associated with lower risk of death over 1 year (absolute risk difference [ARD], -6.7% [95% CI, -7.9% to -5.6%]; hazard ratio [HR], 0.63 [95% CI, 0.57 to 0.69]; P .001). Initiation of pulmonary rehabilitation was significantly associated with lower mortality across start dates ranging from 30 days or less (ARD, -4.6% [95% CI, -5.9% to -3.2%]; HR, 0.74 [95% CI, 0.67 to 0.82]; P .001) to 61 to 90 days after discharge (ARD, -11.1% [95% CI, -13.2% to -8.4%]; HR, 0.40 [95% CI, 0.30 to 0.54]; P .001). Every 3 additional sessions was significantly associated with lower risk of death (HR, 0.91 [95% CI, 0.85 to 0.98]; P = .01).Among fee-for-service Medicare beneficiaries hospitalized for COPD, initiation of pulmonary rehabilitation within 3 months of discharge was significantly associated with lower risk of mortality at 1 year. These findings support current guideline recommendations for pulmonary rehabilitation after hospitalization for COPD, although the potential for residual confounding exists and further research is needed.

Objective/Background: Poor sleep during pregnancy is common and is associated with pregnancy complications. Physical activity (PA) is associated with better sleep in nonpregnant populations. Howeve...

Background Little is known about the safety of nicotine replacement therapy ( NRT ) in smokers hospitalized with coronary heart disease. Methods and Results We examined the short‐term safety of NRT use among smokers hospitalized for coronary heart disease in a geographically and structurally diverse sample of US hospitals in the year 2014. We compared smokers who started NRT in the first 2 days of hospitalization with smokers without any exposure to NRT and adjusted for baseline differences through propensity score matching. Outcomes included inpatient mortality, hospital length of stay, and 1‐month readmission. From 270 hospitals, we included 27 459 smokers (mean age, 58 years; 69% men; 56.9% in intensive care unit), of whom 4885 (17.8%) received NRT (97.2% used the nicotine patch, at a median dose of 21 mg/d for 3 days). After propensity matching, covariates were well balanced within each patient group. Among patients with myocardial infarction, compared with patients who did not receive NRT , those who received NRT showed no difference in mortality (2.1% versus 2.3%; P =0.98), mean length of stay (4.4±3.5 versus 4.3±3.3 days; P =0.60), or 1‐month readmission (15.8% versus 14.6%; P =0.31). Results were similar for patients undergoing percutaneous coronary intervention or coronary artery bypass surgery. Conclusions Among smokers hospitalized for treatment of coronary heart disease, use of NRT was not associated with any differences in short‐term outcomes. Given the known beneficial effects of NRT in treating nicotine withdrawal, reducing cravings, and promoting smoking cessation after discharge, our findings suggest that NRT is a safe and reasonable treatment option.

This cohort study assesses the rate and timing of urologic procedures performed after an emergency department visit for renal colic and the factors associated with receipt of an intervention within 60 days., Key Points Question When an adult patient is discharged from the emergency department after an episode of renal colic, what is their likelihood of having a urologic procedure within the next 60 days? Findings In this cohort study of 66 218 unique index visits by 55 314 patients 18 to 64 years of age, 5.0% of patients underwent a urologic procedure by 7 days and 12.7% underwent a urologic procedure by 60 days. Patients with Medicaid were less likely to undergo urologic procedures. Meaning These findings may inform emergency department–based shared decision-making about imaging options and outpatient follow-up for patients younger than 65 years., Importance Little is known about the timing of urologic interventions in patients with renal colic discharged from the emergency department. Understanding patients’ likelihood of a subsequent urologic intervention could inform decision-making in this population. Objectives To examine the rate and timing of urologic procedures performed after an emergency department visit for renal colic and the factors associated with receipt of an intervention. Design, Setting, and Participants This retrospective cohort study used the Massachusetts All Payers Claims Database to identify patients 18 to 64 years of age who were seen in a Massachusetts emergency department for renal colic from January 1, 2011, to October 31, 2014, Patients were identified via International Classification of Diseases, Ninth Revision codes, and all medical care was linked, enabling identification of subsequent health care use. Data analysis was performed from January 1, 2017, to December 31, 2018. Main Outcomes and Measures The main outcome was receipt of urologic procedure within 60 days. Secondary outcomes included rates of return emergency department visit and urologic and primary care follow-up. Results A total of 66 218 unique index visits by 55 314 patients (mean [SD] age, 42.6 [12.4] years; 33 590 [50.7%] female; 25 411 [38.4%] Medicaid insured) were included in the study. A total of 5851 patients (8.8%) had visits resulting in admission at the index encounter, and 1774 (2.7%) had visits resulting in a urologic procedure during that admission. Of the 60 367 patient visits resulting in discharge from the emergency department, 3018 (5.0%) led to a urologic procedure within 7 days, 4407 (7.3%) within 14 days, 5916 (9.8%) within 28 days, and 7667 (12.7%) within 60 days. A total of 3226 visits (5.3%) led to a subsequent emergency department visit within 7 days and 6792 (11.3%) within 60 days. For the entire cohort (admitted and discharged patients), 39 189 (59.2%) had contact with a urologist or primary care practitioner within 60 days. Having Medicaid-only insurance was associated with lower rates of urologic procedures (odds ratio, 0.70; 95% CI, 0.66-0.74) and urologic follow-up (5.6% vs 8.8%; P

Objectives Poor sleep among postpartum women is associated with adverse maternal outcomes. Physical activity (PA) is associated with better sleep. However, few studies have been conducted among postpartum Hispanic women. The objective of this study was to examine the association between PA and sleep quality and duration among postpartum Hispanic women. Design A cross-sectional analysis using baseline data from Estudio PARTO, an ongoing randomized controlled trial aimed at reducing type 2 diabetes risk among Hispanic women. Setting Baystate Medical Center, in Western Massachusetts, which serves an ethnically and socioeconomically diverse population. Participants Hispanic women, at elevated risk for type 2 diabetes, at a mean of 11 weeks (SD = 4.5) postpartum. Measurements PA was measured with the Pregnancy Physical Activity Questionnaire (PPAQ), and sleep was measured with the Pittsburgh Sleep Quality Index (PSQI). Results Mean sleep duration was 5.9 hour/night (SD = 1.7) and PSQI score was 6.5 (SD = 3.9). In multivariable logistic models, sports/exercise was associated with lower odds of very poor sleep quality (PSQI >10) (OR = 0.18, 95% CI = 0.05 to 0.69). Sports/exercise (OR = 0.05, 95% CI = 0.01 to 0.26) and vigorous intensity PA (OR = 0.13, 95% CI = 0.04 to 0.42) were associated with lower odds of short (vs normal) sleep duration. There were no statistically significant relationships between PA in any other domain or intensity and sleep quality or duration Conclusions Findings can inform interventions designed to improve postpartum sleep via increasing opportunities for exercise among postpartum women.

Background: Preterm birth and low birthweight contribute substantially to the disproportionately high infant mortality rates experienced by Puerto Ricans in the United States. The purpose of this study was to examine whether the timing and pattern of prenatal psychosocial stress increased risk of adverse birth outcomes in this high-risk population. Materials and Methods: Proyecto Buena Salud was a prospective cohort study conducted from 2006 to 2011 among predominantly Puerto Rican women. Participants (n = 1,267) were interviewed in early, mid-, and late pregnancy. We evaluated associations between early and mid-pregnancy stress (Perceived Stress Scale) and preterm birth and low birthweight, and stress at each pregnancy time point and small for gestational age (SGA). Results: Elevated levels of perceived stress in mid-pregnancy increased risk for preterm birth and low birthweight in adjusted analyses, with a linear trend observed for each increasing quartile of stress (p(trend) = 0.01). Women in the highest quartile of stress experienced three times the risk for preterm birth (odds ratio [OR] = 3.50, confidence interval [95% CI]: 1.38–8.87) and low birthweight (OR = 3.53, 95% CI = 1.27–9.86) compared with women in the lowest quartile. Early pregnancy stress was not associated with preterm birth or low birthweight. Increase in stress from early to late pregnancy increased risk for SGA (OR = 1.90, 95% CI = 1.01–3.59); no associations were found between stress at any timepoint and SGA. Conclusion: Elevated levels of mid-pregnancy perceived stress increased risk for preterm birth and low birthweight, and an increase in stress over the course of pregnancy increased risk for SGA in a population of predominantly Puerto Rican women.