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BACKGROUND: Evidence on the comparative outcomes following percutaneous microaxial ventricular assist devices (pVAD) versus intra-aortic balloon pump for nonacute myocardial infarction cardiogenic shock is limited. METHODS AND RESULTS: We included 704 and 2140 Medicare fee-for-service beneficiaries aged 65 to 99 years treated with pVAD and intra-aortic balloon pump, respectively, for nonacute myocardial infarction cardiogenic shock from 2016 to 2020. Patients treated using pVAD compared with those treated using intra-aortic balloon pump were more likely to be concurrently treated with mechanical ventilation, renal replacement therapy, and blood transfusions. We computed propensity scores for undergoing pVAD using patient- and hospital-level factors and performed a matching weight analysis. The use of pVAD was associated with higher 30-day mortality (adjusted odds ratio, 1.92 [95% CI, 1.59-2.33]) but not associated with in-hospital bleeding (adjusted odds ratio, 1.00 [95% CI, 0.81-1.24]), stroke (adjusted odds ratio, 0.91 [95% CI, 0.56-1.47]), sepsis (OR, 0.91 [95% CI, 0.64-1.28]), and length of hospital stay (adjusted mean difference, +0.4 days [95% CI, -1.4 to +2.3]). A quasi-experimental instrumental variable analysis using the cross-sectional institutional practice preferences showed similar patterns, though not statistically significant (adjusted odds ratio, 1.38; 95% CI, 0.28-6.89). CONCLUSIONS: Our investigation using the national sample of Medicare beneficiaries showed that the use of pVAD compared with intra-aortic balloon pump was associated with higher mortality in patients with nonacute myocardial infarction cardiogenic shock. Providers should be cautious about the use of pVAD for nonacute myocardial infarction cardiogenic shock, while adequately powered high-quality randomized controlled trials are warranted to determine the clinical effects of pVAD.

BackgroundEnd-of-life (EOL) care patterns may differ by physician age given differences in how physicians are trained or changes associated with aging. We sought to compare patterns of EOL care delivered to older Americans according to physician age.MethodsWe conducted a cross-sectional study of a 20% sample of Medicare fee-for-service beneficiaries aged ≥66 years who died in 2016-2019 (n = 487,293). We attributed beneficiaries to the physician who had >50% of primary care visits during the last 6 months of life. We compared beneficiary-level outcomes by physician age (

OBJECTIVES: Although guidelines recommend antiviral therapy for outpatients with COVID-19 who are at high risk of progressing to severe conditions, such as older adults, many patients do not receive appropriate treatment. Little is known, however, about the physician factors associated with the prescription of guideline-recommended antiviral therapy for patients with COVID-19. DESIGN: A cross-sectional study. SETTING: Data including outpatient visits in primary care clinics in Japan from April to August 2023. PARTICIPANTS: We analysed 30 953 outpatients aged ≥65 years treated with COVID-19 (mean (SD) age, 75.0 (7.6) years; 17 652 women (57.0%)) in 1394 primary care clinics. OUTCOME MEASURES: The primary outcome was the prescription of guideline-recommended antivirals (ie, nirmatrelvir-ritonavir or molnupiravir), adjusted for patient characteristics, months of visits and regions. RESULTS: Antiviral prescriptions were concentrated among a small proportion of physicians; for example, the top 10% of physicians that had the largest number of nirmatrelvir-ritonavir prescriptions accounted for 92.4% of all nirmatrelvir-ritonavir prescriptions. After adjusting for potential confounders, physicians with higher patient volumes were more likely to prescribe guideline-recommended antivirals to their patients (adjusted OR (aOR) for high vs low volume, 1.76; 95% CI 1.31 to 2.38; adjusted p

BACKGROUND: Understanding how the coronavirus disease 2019 (COVID-19) pandemic affected site of death-an important patient-centered outcome related to end-of-life care-would inform healthcare system resiliency in future public health emergencies. OBJECTIVE: To evaluate the changes in site of death during the COVID-19 pandemic among older adults without a COVID-19 diagnosis. DESIGN: Using a quasi-experimental difference-in-differences method, we estimated net changes in site of death during the pandemic period (March-December 2020) from the pre-pandemic period (January-February 2020), using data on the same months in prior years (2016-2019) as the control. PARTICIPANTS: A 20% sample of Medicare Fee-for-Service beneficiaries aged 66 years and older who died in 2016-2020. We excluded beneficiaries with a hospital diagnosis of COVID-19. MAIN MEASURES: We assessed each of the following sites of death separately: (1) home or community; (2) acute care hospital; and (3) nursing home. KEY RESULTS: We included 1,133,273 beneficiaries without a hospital diagnosis of COVID-19. We found that the proportion of Medicare beneficiaries who died at home or in the community setting increased (difference-in-differences [DID] estimate, + 3.1 percentage points [pp]; 95% CI, + 2.6 to + 3.6 pp; P

OBJECTIVES: To examine changes in the 30-day surgical mortality rate after common surgical procedures during the COVID-19 pandemic and investigate whether its impact varies by urgency of surgery or patient race, ethnicity and socioeconomic status. DESIGN: We used a quasi-experimental event study design to examine the effect of the COVID-19 pandemic on surgical mortality rate, using patients who received the same procedure in the prepandemic years (2016-2019) as the control, adjusting for patient characteristics and hospital fixed effects (effectively comparing patients treated at the same hospital). We conducted stratified analyses by procedure urgency, patient race, ethnicity and socioeconomic status (dual-Medicaid status and median household income). SETTING: Acute care hospitals in the USA. PARTICIPANTS: Medicare fee-for-service beneficiaries aged 65-99 years who underwent one of 14 common surgical procedures from 1 January 2016 to 31 December 2020. MAIN OUTCOME MEASURES: 30-day postoperative mortality rate. RESULTS: Our sample included 3 620 689 patients. Surgical mortality was higher during the pandemic, with peak mortality observed in April 2020 (adjusted risk difference (aRD) +0.95 percentage points (pp); 95% CI +0.76 to +1.26 pp; p

BACKGROUND: To investigate the individual profile of each SGLT2 (sodium-glucose cotransoporter-2) inhibitor in patients with different backgrounds. METHODS AND RESULTS: This study included 21 placebo-controlled randomized controlled trials with a total of 96 196 participants, investigating empagliflozin, ertugliflozin, dapagliflozin, canagliflozin, and sotagliflozin. The primary efficacy end point was the composite of cardiovascular death and hospitalizations for heart failure. The secondary efficacy end points were all-cause death, cardiovascular death, hospitalizations for heart failure, kidney disease progression, and acute kidney injury. We conducted subgroup analyses based on the underlying comorbidities, including diabetes and chronic kidney disease. Safety end points were also assessed among SGLT2 inhibitors in the overall cohort. In the overall cohort, there were no significant differences in the primary efficacy outcome among the SGLT2 inhibitors, while empagliflozin (hazard ratio [HR], 0.70 [95% CI, 0.53-0.92]) and dapagliflozin (HR, 0.73 [95% CI, 0.56-0.96]) were associated with lower risk of acute kidney injury than sotagliflozin. The presence or absence of diabetes did not alter the results. In patients with chronic kidney disease, there were no differences in the efficacy outcomes among SGLT2 inhibitors, while in patients without chronic kidney disease, empagliflozin was associated with lower risk of the primary outcome compared with ertugliflozin (HR, 0.77 [95% CI, 0.60-0.98]). For safety outcomes, no significant differences were observed in amputation, urinary tract infection, genital infection, hypoglycemia, and diabetic ketoacidosis. CONCLUSIONS: The differences in reducing cardiovascular and kidney outcomes as well as safety profiles across SGLT2 inhibitors were not consistently significant, although empagliflozin might be preferred in patients without chronic kidney disease. Further investigations are needed to better understand the mechanism and clinical effectiveness of each SGLT2 inhibitor in certain populations.

OBJECTIVES: To investigate the impact of no cost sharing on paediatric care on usage and health outcomes, and whether the effect varies by household income levels. DESIGN: Regression discontinuity design. SETTING: Nationwide medical claims database in Japan. PARTICIPANTS: Children aged younger than 20 years from April 2018 to March 2022. EXPOSURE: Co-insurance rate that increases sharply from 0% to 30% at a certain age threshold (the threshold age varies between 6 and 20 years depending on region). PRIMARY OUTCOME MEASURES: The outpatient care usage (outpatient visit days and healthcare spending for outpatient care) and inpatient care (experience of any hospitalisation and healthcare spending for inpatient care). RESULTS: Of 244 549 children, 49 556 participants were in the bandwidth and thus included in our analyses. Results from the regression discontinuity analysis indicate that no cost sharing was associated with a significant increase in the number of outpatient visit days (+5.26 days; 95% CI, +4.89 to +5.82; p

BACKGROUND: In medicine, clinicians treat individuals under an implicit assumption that high-risk patients would benefit most from the treatment (high-risk approach). However, treating individuals with the highest estimated benefit using a novel machine-learning method (high-benefit approach) may improve population health outcomes. METHODS: This study included 10 672 participants who were randomized to systolic blood pressure (SBP) target of either 0) versus the high-risk approach (treating individuals with SBP ≥130 mmHg). Using transportability formula, we also estimated the effect of these approaches among 14 575 US adults from National Health and Nutrition Examination Surveys (NHANES) 1999-2018. RESULTS: We found that 78.9% of individuals with SBP ≥130 mmHg benefited from the intensive SBP control. The high-benefit approach outperformed the high-risk approach [average treatment effect (95% CI), +9.36 (8.33-10.44) vs +1.65 (0.36-2.84) percentage point; difference between these two approaches, +7.71 (6.79-8.67) percentage points, P-value

BackgroundGeriatric training is designed to prepare physicians to meet the complex needs of older adults, including persons with dementia at the end-of-life (EOL) stage. We sought to compare patterns of EOL care delivered to persons with dementia between physicians with versus without geriatric training.MethodsWe conducted a cross-sectional study of a 20% random sample of fee-for-service Medicare beneficiaries with dementia who died in 2016-2018 (n = 99,631). We attributed beneficiaries to a physician who had the largest number of primary care visits during the last 6 months of life and determined whether the physician was trained in geriatrics. Our outcome measures included: (i) advance care planning (ACP) and palliative care (e.g., ACP, hospice enrollment in the last 90 days of life), and (ii) high-intensity EOL care (e.g., emergency department visits or hospital admissions in the last 30 days of life).ResultsBeneficiaries with dementia under the care of physicians with geriatric training had a higher proportion of ACP (adjusted proportion, 15.8% vs. 13.0%; p

BackgroundDespite possible major adverse cognitive, physical, social, and behavioral consequences, little is known about how persons living with dementia perceive satisfaction with life, a key component of well-being. We sought to examine (i) whether persons living with dementia perceive a lower level of satisfaction compared to their peers without dementia and (ii) whether the associations between individual characteristics and life satisfaction are different between persons living with and without dementia.MethodsUsing a nationally representative sample of community-dwelling older adults aged ≥70 years in the U.S. from the Health and Retirement Study, we compared scores on the Satisfaction with Life Scale (SWLS), a self-reported 5-item scale ranging from 1 to 7 (more satisfaction), between persons with probable dementia (n = 341) and those without (n = 5530), adjusting for individual characteristics. We also tested whether the associations between the individual characteristics and SWLS differ by dementia status.ResultsScores on SWLS did not differ between persons with probable dementia and those without when adjusting for individual characteristics including limitations in activities of daily living (ADL) (adjusted difference, -0.09; 95% CI, -0.33 to +0.15; p-value, 0.45). However, dementia status was associated with lower life satisfaction through the mediation of limitations in ADL (total effect, -0.29; bootstrapped 95% CI, -0.47 to -0.12). Most individual characteristics associated with lower life satisfaction were similar in the two groups, including younger age, more limitations in ADL, and depression. Less wealth was associated with lower satisfaction among persons without dementia but not among those with probable dementia.ConclusionsDementia status was only modestly associated with lower life satisfaction through the mediation of limitations in ADL among participants who were able to provide response. Future research is warranted to determine whether life satisfaction can be used as a meaningful outcome when evaluating well-being among persons living with dementia.

ObjectiveTo assess inequities in mortality by race and sex for eight common surgical procedures (elective and non-elective) across specialties in the United States.DesignRetrospective cohort study.SettingUS, 2016-18.Participants1 868 036 Black and White Medicare beneficiaries aged 65-99 years undergoing one of eight common surgeries: repair of abdominal aortic aneurysm, appendectomy, cholecystectomy, colectomy, coronary artery bypass surgery, hip replacement, knee replacement, and lung resection.Main outcome measureThe main outcome measure was 30 day mortality, defined as death during hospital admission or within 30 days of the surgical procedure.ResultsPostoperative mortality overall was higher in Black men (1698 deaths, adjusted mortality rate 3.05%, 95% confidence interval 2.85% to 3.24%) compared with White men (21 833 deaths, 2.69%, 2.65% to 2.73%), White women (21 847 deaths, 2.38%, 2.35% to 2.41%), and Black women (1631 deaths, 2.18%, 2.04% to 2.31%), after adjusting for potential confounders. A similar pattern was found for elective surgeries, with Black men showing a higher adjusted mortality (393 deaths, 1.30%, 1.14% to 1.46%) compared with White men (5650 deaths, 0.85%, 0.83% to 0.88%), White women (4615 deaths, 0.82%, 0.80% to 0.84%), and Black women (359 deaths, 0.79%, 0.70% to 0.88%). This 0.45 percentage point difference implies that mortality after elective procedures was 50% higher in Black men compared with White men. For non-elective surgeries, however, mortality did not differ between Black men and White men (1305 deaths, 6.69%, 6.26% to 7.11%; and 16 183 deaths, 7.03%, 6.92% to 7.14%, respectively), although mortality was lower for White women and Black women (17 232 deaths, 6.12%, 6.02% to 6.21%; and 1272 deaths, 5.29%, 4.93% to 5.64%, respectively). These differences in mortality appeared within seven days after surgery and persisted for up to 60 days after surgery.ConclusionsPostoperative mortality overall was higher among Black men compared with White men, White women, and Black women. These findings highlight the need to understand better the unique challenges Black men who require surgery face.

ObjectiveClinical decision support (CDS) alerts may improve health care quality but "alert fatigue" can reduce provider responsiveness. We analyzed how the introduction of competing alerts affected provider adherence to a single depression screening alert.Materials and methodsWe analyzed the audit data from all occurrences of a CDS alert at a large academic health system. For patients who screen positive for depression during ambulatory visits, a noninterruptive alert was presented, offering a number of relevant documentation actions. Alert adherence was defined as the selection of any option offered within the alert. We assessed the effect of competing clinical guidance alerts presented during the same encounter and the total of all CDS alerts that the same provider had seen in the prior 90 days, on the probability of depression screen alert adherence, adjusting for physician and patient characteristics.ResultsThe depression alert fired during 55 649 office visits involving 418 physicians and 40 474 patients over 41 months. After adjustment, physicians who had seen the most alerts in the prior 90 days were much less likely to respond (adjusted OR highest-lowest quartile, 0.38; 95% CI 0.35-0.42; P

ObjectiveTo investigate determining factors of happiness during the COVID-19 pandemic.DesignObservational study.SettingLarge online surveys in Japan before and during the COVID-19 pandemic.ParticipantsA random sample of 25 482 individuals who are representatives of the Japanese population.Main outcome measureSelf-reported happiness measured using a 10-point Likert scale, where higher scores indicated higher levels of happiness. We defined participants with ≥8 on the scale as having high levels of happiness.ResultsAmong the 25 482 respondents, the median score of self-reported happiness was 7 (IQR 6-8), with 11 418 (45%) reporting high levels of happiness during the pandemic. The multivariable logistic regression model showed that meaning in life, having a spouse, trust in neighbours and female gender were positively associated with happiness (eg, adjusted OR (aOR) for meaning in life 4.17; 95% CI 3.92 to 4.43; p

BACKGROUND: While advanced care planning (ACP) is recommended in dementia and cancer care, there are unique challenges in ACP for individuals with dementia, such as the insidious onset and progression of cognitive impairment, potentially leading to high-intensity care at the end of life (EOL) for this population. OBJECTIVE: To compare ACP completion and receipt of high-intensity care at the EOL between decedents with dementia versus cancer. DESIGN: Retrospective longitudinal cohort study. PARTICIPANTS: Participants of the U.S. Health and Retirement Study who died between 2000 and 2014 with dementia (n = 2099) and cancer (n = 1137). MAIN MEASURES: Completion of three types of ACP (living will, durable power of attorney for healthcare [DPOAH], discussions of preferences for EOL care) and three measures of EOL care intensity (in-hospital death, intensive care unit [ICU] care in the last 2 years of life, life support use in the last 2 years of life). KEY RESULTS: Use of living will was lower in dementia than in cancer (adjusted proportion, 49.9% vs. 56.9%; difference, - 7.0 percentage points [pp, 95% CI, - 13.3 to - 0.7]; p = 0.03). Use of DPOAH was similar between the two groups, but a lower proportion of decedents with dementia had discussed preferences compared to decedents with cancer (53.0% vs. 68.1%; - 15.1 pp [95% CI, - 19.3 to - 10.9]; p < 0.001). In-hospital death was higher in dementia than in cancer (29.5% vs. 19.8%; + 9.7 pp [95% CI, + 5.9 to + 13.5]; p < 0.001), although use of ICU care was lower (20.9% vs. 26.1%; - 5.2 pp [95% CI, - 9.8 to - 0.7]; p = 0.03). Use of life support was similar between the two groups. CONCLUSIONS: Individuals with dementia complete ACP less frequently and might be receiving higher-intensity EOL care than those with cancer. Interventions targeting individuals with dementia may be necessary to further improve EOL care for this population.

ObjectiveTo determine changes in industry marketing payments to physicians due to the covid-19 pandemic.DesignQuasi experimental, difference-in-difference study.Data sourceUS nationwide database of licensed physicians, the National Plan and Provider Enumeration System, which was linked to a database of industry marketing payments made to physicians, Open Payments.PopulationAll licensed US physicians from 2018 to 2020 and those who received payments from industry.Main outcome measuresChanges in the value and the number of monthly industry payments physician received before (January-February 2020) and during the pandemic (April-December 2020) were assessed, adjusting for physicians' characteristics (gender and specialty). As the control, data for the same months in 2019 were used. Industry payments by type of payments (eg, meals, travel, consulting fees, speaker compensation, honorariums), were also examined.ResultsAmong 880 589 US physicians included in this study, 267 463 (30.4%) physicians received a total of 4 117 482 non-research payments with $626 million ($710 per physician; £610; €708) in 2020 (40-44% decrease from $1047m in 2018 and $1115m in 2019). Industry payments decreased significantly in the months of the covid-19 pandemic (adjusted change in the value of -48.4%; 95% confidence interval -50.6 to -46.2; P

ObjectivesWe aimed to examine the use and factors associated with the provision of low-value care in Japan.DesignA multicentre observational study.SettingRoutinely collected claims data that include all inpatient and outpatient visits in 242 large acute care hospitals (accounting for approximately 11% of all acute hospitalisations in Japan).Participants345 564 patients (median age (IQR): 62 (40-75) years; 182 938 (52.9%) women) seeking care at least once in the hospitals in the fiscal year 2019.Primary and secondary outcome measuresWe identified 33 low-value services, as defined by clinical evidence, and developed two versions of claims-based measures of low-value services with different sensitivity and specificity (broader and narrower definitions). We examined the number of low-value services, the proportion of patients receiving these services and the proportion of total healthcare spending incurred by these services in 2019. We also evaluated the 2015-2019 trends in the number of low-value services.ResultsServices identified by broader low-value care definition occurred in 7.5% of patients and accounted for 0.5% of overall annual healthcare spending. Services identified by narrower low-value care definition occurred in 4.9% of patients and constituted 0.2% of overall annual healthcare spending. Overall, there was no clear trend in the prevalence of low-value services between 2015 and 2019. When focusing on each of the 17 services accounting for more than 99% of all low-value services identified (narrower definition), 6 showed decreasing trends from 2015 to 2019, while 4 showed increasing trends. Hospital size and patients' age, sex and comorbidities were associated with the probability of receiving low-value service.ConclusionsA substantial number of patients received low-value care in Japan. Several low-value services with high frequency, especially with increasing trends, require further investigation and policy interventions for better resource allocation.

Insulin secretion is regulated in multiple steps, and one of the main steps is in the endoplasmic reticulum (ER). Here, we show that UDP-glucose induces proinsulin ubiquitination by cereblon, and uridine binds and competes for proinsulin degradation and behaves as sustainable insulin secretagogue. Using insulin mutagenesis of neonatal diabetes variant-C43G and maturity-onset diabetes of the young 10 (MODY10) variant-R46Q, UDP-glucose:glycoprotein glucosyltransferase 1 (UGGT1) protects cereblon-dependent proinsulin ubiquitination in the ER. Cereblon is a ligand-inducible E3 ubiquitin ligase, and we found that UDP-glucose is the first identified endogenous proinsulin protein degrader. Uridine-containing compounds, such as uridine, UMP, UTP, and UDP-galactose, inhibit cereblon-dependent proinsulin degradation and stimulate insulin secretion from 3 to 24 h after administration in β-cell lines as well as mice. This late and long-term insulin secretion stimulation is designated a day sustainable insulin secretion stimulation. Uridine-containing compounds are designated as proinsulin degradation regulators.

We previously reported that glucokinase is ubiquitinated and degraded by cereblon with an unknown endogenous glucokinase protein degrader. Here, we show that UDP-glucose is a glucokinase protein degrader. We identified that both glucose and UDP-glucose bind to glucokinase and that both uridine and UDP-glucose bind to cereblon in a similar way to thalidomide. From these results, UDP-glucose was identified as a molecular glue between cereblon and glucokinase. Glucokinase produces glucose-6-phosphate in the pancreas and liver. Especially in β-cells, glucokinase is the main target of glucose for glucose-induced insulin secretion. UDP-glucose administration ubiquitinated and degraded glucokinase, lowered glucose-6-phosphate production, and then reduced insulin secretion in β-cell lines and mice. Maturity-onset diabetes of the young type 2 (MODY2) glucokinaseE256K mutant protein was resistant to UDP-glucose induced ubiquitination and degradation. Taken together, glucokinase ubiquitination and degradation signaling might be impaired in MODY2 patients.

ObjectivesIncreases in obesity and cardiovascular diseases contribute to rapidly growing healthcare expenditures in many countries. However, little is known about whether the population-level health guidance intervention for obesity and cardiovascular risk factors is associated with reduced healthcare utilisation and spending. The aim of this study was to investigate the effect of population-level health guidance intervention introduced nationally in Japan on healthcare utilisation and spending.DesignRetrospective cohort study, using a quasiexperimental regression discontinuity design.SettingJapan's nationwide employment-based health insurers.ParticipantsParticipants in the national health screening programme (from January 2014 to December 2014) aged 40-74 years.PredictorsAssignment to health guidance intervention (counselling on healthy lifestyles, and referral to physicians as needed) determined primarily on whether the individual's waist circumference was above or below the cut-off value in addition to having at least one cardiovascular risk factor.Primary and secondary outcome measuresHealthcare utilisation (the number of outpatient visits days, any medication use and any hospitalisation use) and spending (total medical expenditure, outpatient medical expenditure and inpatient medical expenditure) within 3 years of the intervention.ResultsA total of 51 213 individuals within the bandwidth (±6 cm of waist circumference from the cut-off) out of 113 302 screening participants (median age 50.0 years, 11.9% woman) were analysed. We found that the assignment to the national health guidance intervention was associated with fewer outpatient visit days (-1.3 days; 95% CI, -11.4 to -0.5 days; p=0.03). We found no evidence that the assignment to the health guidance intervention was associated with changes in medication or hospitalisation use, or healthcare spending.ConclusionAmong working-age, male-focused Japanese from a health insurer of companies of civil engineering and construction, the national health guidance intervention might be associated with a decline in outpatient visits, with no change in medication/hospitalisation use or healthcare spending.

BackgroundPrevious studies have demonstrated positive impacts of advance care planning (ACP) on end-of-life (EOL) care. We sought to examine trends in ACP and EOL care intensity among persons living with dementia who required surrogate decision-making in their final days of life.MethodsWe analyzed the participants of the Health and Retirement Study (HRS), a nationally representative longitudinal panel study of U.S. residents, with dementia 70 years and older who required surrogate decision-making in the final days of life and died between 2000 and 2014. Based on surrogate reports after the death of a participant, our study measured the completion of three specific types of patient-engaged ACP (written EOL care instructions, assignment of a durable power of attorney for healthcare, patient engagement in EOL care discussions) and four measures of EOL care in the final days of life (death in hospital, receipt of life-prolonging treatments, limiting or withholding certain treatments, and receipt of comfort-oriented care). All analyses accounted for the complex survey design of HRS.ResultsAmong 870 adults (weighted N = 2,812,380) with dementia who died in 2000-2014 and required surrogate decision-making at EOL, only 34.8% of patients participated in all three aspects of ACP, and there was not a significant increase in ACP completion between 2000 and 2014. The receipt of life-prolonging treatments in the final days of life has increased over time (adjusted change per year, 1.4 percentage points [pp]; 95% CI, 0.5 to 2.2 pp; P-for-trend = 0.002), while the percentage of death in hospital, limiting or withholding certain treatments, or comfort-oriented care did not change.ConclusionsOur findings suggest that the rates of ACP completion have not increased over time despite its potential benefits and life-prolonging treatments are still common among PLWD who require surrogate decision-making, a population who might benefit greatly from early ACP.

BackgroundA study has shown that industry payments to physicians for drugs are associated not only with higher drug prescriptions but also with higher non-drug costs due to additional utilization of healthcare services. However, the association between industry payments to cardiologists for antiplatelet drugs and the costs and number of percutaneous coronary interventions they perform has not been investigated.ObjectiveTo examine the association between industry payments to cardiologists for antiplatelet drugs and the costs and number of percutaneous coronary interventions they perform.DesignUsing the 2016 Open Payments Database linked to the 2017 Medicare Provider Utilization and Payment Data, we examined the association between the value of industry payments related to the antiplatelet drugs prasugrel and ticagrelor and healthcare spending and volume for cardiovascular procedures, adjusted for potential cofounders.SubjectsA total of 7456 cardiologists who performed diagnostic cardiac catheterizations on Medicare beneficiaries in 2017.Main measuresPrimary outcomes included (1) healthcare spending on cardiac procedures, (2) diagnostic cardiac catheterization volumes, and (3) rates of coronary stenting. Secondary outcomes were total expenditures for all drugs and for antiplatelet drugs.Key resultsIndustry payments for antiplatelet drugs were associated with higher healthcare spending on cardiac procedures (adjusted difference, +$50.9 for additional $100 industry payments; 95% CI, +$25.5 to +$76.2; P < 0.001), diagnostic cardiac catheterizations (+0.1 procedures per cardiologist; 95% CI, +0.03 to +0.1; P=0.001), and stent use (+0.5 per 1000 diagnostic cardiac catheterizations per cardiologist; 95% CI, +0.2 to +0.9; P=0.002). Industry payments for antiplatelet drugs were associated with higher total costs for all drugs and antiplatelet drugs.ConclusionsIndustry payments to cardiologists for antiplatelet drugs were associated with both prescribing of antiplatelet drugs and the use of cardiac procedures and stents. Further research is warranted to understand whether the observed associations are causal or reflect a greater propensity for higher volume proceduralists to have relationships with industry.

ObjectivesExisting literature indicates that multimorbidity, mental health (MH) conditions, substance use disorders (SUDs), and social determinants of health are hallmarks of high-need, high-cost patients. Health Resources and Services Administration-funded health centers (HCs) provide care to nearly 30 million patients, but data on their patients' complexity and utilization patterns are limited. We identified subgroups of HC patients based on latent concepts of complexity and utilization.Study designWe used cross-sectional national data from the 2014 Health Center Patient Survey and latent class analyses to identify distinct and homogenous groups of complex high-utilizing patients aged 18 to 64 years.MethodsWe included indicators of chronic conditions (CCs), MH, SUD risk, and health behavior to measure complexity. We used number of outpatient and emergency department visits in the past year to measure utilization.ResultsHC patients were separated in 9 distinct groups based on 3 complexity latent classes (MH, multiple CCs, and low risk) and 3 utilization classes (low, high, and superutilizers). Conditions associated with each subgroup differed. The highest prevalence of bipolar disorder (45%) and high SUD risk (6%) was observed among MH superutilizers, whereas the highest prevalence of cardiovascular disease (48%) and obesity (96%) was seen among CC superutilizers. Most MH superutilizer patients concurrently had MH conditions and obesity and were smokers, but most CC superutilizer patients concurrently had hypertension, obesity, and cardiovascular disease.ConclusionsOur examination of complexity and utilization indicated distinct HC patient populations. Managing the care of each group may require different targeted intervention approaches such as multidisciplinary care teams that include MH providers or specialists.

BACKGROUND: The coronavirus disease 2019 (COVID-19) pandemic has had a widespread significant impact on mental health. However, the effect of providing care to family members (informal caregiving) on changes in mental health status during the pandemic remains unclear. METHODS: Using cross-sectional data from a large internet survey conducted between August and September 2020, we investigated the association of informal caregiving status with the incidence of mental health deterioration (increased loneliness, self-reported deterioration in mental health, and new suicidal ideation) in Japan during the COVID-19 pandemic. RESULTS: Among 25,482 participants (mean age 48.8 [standard deviation 17.3]; 50.3% women), 2,500 (9.8%) were providing informal care during the pandemic. After adjusting for potential confounders, informal caregivers were more likely than non-caregivers to experience increased loneliness (adjusted odds ratio [aOR] 2.16; 95% confidence interval [CI] 1.70-2.76), self-reported deterioration in mental health (aOR 1.54; 95% CI 1.14-2.08), and new incidence of suicidal ideation (aOR 3.65; 95% CI 1.92-6.92). The degree of mental health deterioration depended on the intensity of care. For example, the incidence rates of new suicidal ideation were 15.0%, 5.2%, and 3.6% for individuals who provided high-intensity caregiving, those who provided low-intensity caregiving, and non-caregivers, respectively (p-for-trend

Background and aimsObesity has been reported to be one of the most frequent comorbidities in COVID-19 patients and associated with higher rates of in-hospital mortality compared to non-obese patients. Acute kidney injury (AKI) is also known to be a complication associated with obesity in critically-ill COVID-19 patients. We aimed to investigate whether obesity was associated with increased risk of in-hospital mortality and AKI among patients with COVID-19 treated with corticosteroids.MethodsWe utilized 9965 hospitalized COVID-19 patient data and divided patients who were treated with corticosteroids into 6 groups by body mass index (BMI) (less than 18.5, 18.5-25, 25-30, 30-35, 35-40, 40 kg/m2 or greater). The association between BMI and in-hospital mortality and between BMI and incidence rate of AKI during admission among COVID-19 patients receiving corticosteroids were retrospectively investigated.ResultsThere were 4587 study participants receiving corticosteroids (mean age 66.5 ± 15.5 years, men 56.6%, mean BMI 29.0 ± 7.2 kg/m2). The smooth spline curve suggested a J-shape association between BMI and in-hospital mortality. Patients with BMI above 40 kg/m2 exhibited a higher in-hospital mortality and higher incidence rate of AKI during admission compared to patients with BMI between 25 and 30 kg/m2. The differences in in-hospital mortality and the rate of AKI were larger among patients with severe COVID-19.ConclusionsClass III obesity was associated with high in-hospital mortality and AKI in patients with COVID-19 treated by corticosteroids. Clinicians must stay vigilant on the impact of class III obesity and development of AKI to disease trajectory of COVID-19 patients.

BackgroundResearch suggests that preventive measures are critical to reducing the spread of coronavirus disease 2019 (COVID-19), but evidence regarding the association between trust in government and the practice of preventive measures is limited.ObjectiveTo examine whether the practice of preventive measures against COVID-19 differs by one's level of trust in government.DesignA cross-sectional analysis using the Japan COVID-19 and Society Internet Survey (JACSIS) conducted in August and September 2020.ParticipantsA nationally representative sample of Japanese individuals aged 15 through 79 years.Main measuresThe primary outcome was the composite score for COVID-19 preventive measures, defined as the percentage of preventive measures an individual reported to be practicing (out of nine measures: social distancing, wearing masks, avoiding closed spaces, avoiding crowded spaces, avoiding close contact settings, hand washing, avoiding touching one's face, respiratory hygiene, and surface disinfection). The secondary outcomes were (1) support for stay-at-home requests, (2) use of a contact-tracing app, and (3) receipt of the influenza vaccine in the previous season.Key resultsOur analysis included a total of 25,482 individuals. After adjusting for potential confounders, we found that individuals with high trust in government were likely to practice preventive measures more frequently compared to those with low trust (adjusted composite scores, 83.8% for high- vs. 79.5% for low-trust individuals; adjusted difference, +4.3 percentage points [pp]; 95% CI, +2.4 to +6.2pp; P

ObjectiveIt is unclear whether relatively low glycated haemoglobin (HbA1c) levels are beneficial or harmful for the long-term health outcomes among people without diabetes. We aimed to investigate the association between low HbA1c levels and mortality among the US general population.MethodsThis study includes a nationally representative sample of 39 453 US adults from the National Health and Nutrition Examination Surveys 1999-2014, linked to mortality data through 2015. We employed the parametric g-formula with pooled logistic regression models and the ensemble machine learning algorithms to estimate the time-varying risk of all-cause and cardiovascular mortality by HbA1c categories (low, 4.0 to

ObjectivesThere have been concerns that patients with chronic conditions may be avoiding in-person physician visits due to fear of COVID-19, leading to lower quality of care. We aimed to investigate changes in physician visits and medication prescriptions for chronic diseases before and during the COVID-19 pandemic at the population level.DesignRetrospective cohort study.SettingNationwide claims data in Japan, 2018-2020.ParticipantsWorking-age population (aged 18-74 years) who visited physicians and received any prescriptions for major chronic diseases (hypertension, diabetes and dyslipidaemia) before the pandemic.Outcome measuresThe outcomes were the monthly number of physician visits, the monthly proportion of physician visits and the monthly proportion of days covered by prescribed medication (PDC) during the pandemic (April-May 2020, as the first state of emergency over COVID-19 was declared on 7 April, and withdrawn nationally on 25 May).ResultsAmong 10 346 patients who visited physicians for chronic diseases before the pandemic, we found a temporary decline in physician visits (mean number of visits was 1.9 in March vs 1.7 in April; p

ObjectiveTo investigate the factors associated with serious psychological distress (SPD) during the COVID-19 pandemic in Japan.DesignNationwide cross-sectional study using survey data.SettingInternet survey using sampling weights for national estimates conducted between 25 August and 30 September 2020 in Japan.ExposuresDemographics (age, gender), socioeconomic status (income level, employment type, educational attainment, marital status, family composition and caregiving burden); the experience of domestic violence (DV), the state of emergency and fear of and stigma related to COVID-19.Main outcome measuresPrevalence of SPD, defined as Kessler 6 Scale score ≥13.ResultsAmong 25 482 respondents, 10.0% met the criteria of SPD. Overall, women (adjusted OR (aOR) 1.59; 95% CI 1.17 to 2.16; p=0.003), ages 15-29 (aOR 2.35 compared with ages 45-59 years; 95% CI 1.64 to 3.38; p

BackgroundEvidence is limited as to whether the introduction of the Affordable Care Act (ACA)'s Medicaid expansions was associated with improvements in cardiovascular risk factors at the population level.ObjectiveTo examine the association between the ACA Medicaid expansions and changes in cardiovascular risk factors among low-income individuals during the first 3 years of the implementation of the ACA Medicaid expansions at the national level.DesignA quasi-experimental difference-in-differences (DID) analysis to compare outcomes before (2005-2012) and after (2015-2016) the implementation of the ACA Medicaid expansions between individuals in states that expanded Medicaid and individuals in non-expansion states.ParticipantsA nationally representative sample of individuals aged 19-64 years with family incomes below 138% of the federal poverty level from the 2005-2016 National Health and Nutrition Examination Survey (NHANES).InterventionACA Medicaid expansions.Main measuresCardiovascular risk factors included (1) systolic and diastolic blood pressure, (2) hemoglobin A1c (HbA1c) level, and (3) cholesterol levels (low-density lipoprotein cholesterol, triglyceride, and high-density lipoprotein cholesterol).Key resultsA total of 9177 low-income individuals were included in our analysis. We found that the ACA Medicaid expansions were associated with a lower systolic blood pressure (DID estimate, - 3.03 mmHg; 95% CI, - 5.33 mmHg to - 0.73 mmHg; P = 0.01; P = 0.03 after adjustment for multiple comparisons) and lower HbA1c level (DID estimate, - 0.14 percentage points [pp]; 95% CI, - 0.24 pp to - 0.03 pp; P = 0.01; P = 0.03 after adjustment for multiple comparisons). We found no evidence that diastolic blood pressure and cholesterol levels changed following the ACA Medicaid expansions.ConclusionUsing the nationally representative data of individuals who were affected by the ACA, we found that the ACA Medicaid expansions were associated with a modest improvement in cardiovascular risk factors related to hypertension and diabetes during the first 3 years of implementation.

BackgroundThe rapidly increased spending on insulin is a major public health issue in the United States. Industry marketing might be one of the upstream determinants of physicians' prescription of long-acting insulin-the most commonly used and costly type of insulin, but the evidence is lacking. We therefore aimed to investigate the association between industry payments to physicians and subsequent prescriptions of long-acting insulin.Methods and findingsUsing the databases of Open Payments and Medicare Part D, we examined the association between the receipt of industry payments for long-acting insulin in 2016 and (1) the number of claims; (2) the costs paid for all claims; and (3) the costs per claim of long-acting insulin in 2017. We also examined the association between the receipt of payments and the change in these outcomes from 2016 to 2017. We employed propensity score matching to adjust for the physician-level characteristics (sex, years in practice, specialty, and medical school attended). Among 145,587 eligible physicians treating Medicare beneficiaries, 51,851 physicians received industry payments for long-acting insulin worth $22.3 million. In the propensity score-matched analysis including 102,590 physicians, we found that physicians who received the payments prescribed a higher number of claims (adjusted difference, 57.8; 95% CI, 55.8 to 59.7), higher costs for total claims (adjusted difference, +$22,111; 95% CI, $21,387 to $22,836), and higher costs per claim (adjusted difference, +$71.1; 95% CI, $69.0 to $73.2) of long-acting insulin, compared with physicians who did not receive the payments. The association was also found for changes in these outcomes from 2016 to 2017. Limitations to our study include limited generalizability, confounding, and possible reverse causation.ConclusionsIndustry marketing payments to physicians for long-acting insulin were associated with the physicians' prescriptions and costs of long-acting insulin in the subsequent year. Future research is needed to assess whether policy interventions on physician-industry financial relationships will help to ensure appropriate prescriptions and limit overall costs of this essential drug for diabetes care.

ObjectiveTo investigate the association between participation in government subsidies for domestic travel (subsidise up to 50% of all travel expenses) introduced nationally in Japan on 22 July 2020 and the incidence of symptoms indicative of COVID-19 infections.DesignCross-sectional analysis of nationally representative survey data.SettingInternet survey conducted between 25 August and 30 September 2020 in Japan. Sampling weights were used to calculate national estimates.Participants25 482 survey respondents (50.3% (12 809) women; mean (SD) age, 48.8 (17.4) years).Main outcome measuresIncidence rate of five symptoms indicative of the COVID-19 infection (high fever, sore throat, cough, headache, and smell and taste disorder) within the past month of the survey, after adjustment for characteristics of individuals and prefecture fixed effects (effectively comparing individuals living in the same prefecture).ResultsAt the time of the survey, 3289 (12.9%) participated in the subsidy programme. After adjusting for potential confounders, we found that participants in the subsidy programme exhibited higher incidence of high fever (adjusted rate, 4.7% for participants vs 3.7% for non-participants; adjusted OR (aOR) 1.83; 95% CI 1.34 to 2.48; p

ObjectivesEvidence suggests that homeless patients experience worse quality of care and poorer health outcomes across a range of medical conditions. It remains unclear, however, whether differences in care delivery at safety-net versus non-safety-net hospitals explain these disparities. We aimed to investigate whether homeless versus non-homeless adults hospitalised for cardiovascular conditions (acute myocardial infarction (AMI) and stroke) experience differences in care delivery and health outcomes at safety-net versus non-safety-net hospitals.DesignCross-sectional study.SettingData including all hospital admissions in four states (Florida, Massachusetts, Maryland, and New York) in 2014.ParticipantsWe analysed 167 105 adults aged 18 years or older hospitalised for cardiovascular conditions (age mean=64.5 years; 75 361 (45.1%) women; 2123 (1.3%) homeless hospitalisations) discharged from 348 hospitals.Outcome measuresRisk-adjusted diagnostic and therapeutic procedure and in-hospital mortality, after adjusting for patient characteristics and state and quarter fixed effects.ResultsAt safety-net hospitals, homeless adults hospitalised for AMI were less likely to receive coronary angiogram (adjusted OR (aOR), 0.42; 95% CI, 0.36 to 0.50; p

BackgroundIn low- and middle-income countries, there is scarcity of validated and reliable measurement tools for health facility management, and many interventions to improve primary health care (PHC) facilities are designed without adequate evidence base on what management practices are critical.ObjectiveThis article developed and validated a scorecard to measure management practices at primary health care facilities under the performance-based financing (PBF) scheme in Nigeria.MethodsRelevant management practice domains and indicators for PHC facilities were determined based on literature review and a prior qualitative study conducted in Nigeria. The domains and indicators were tested for face validity via experts review and organized into an interviewer-administered scorecard. A stratified random sampling of PHC facilities in three States in Nigeria was conducted to assess the reliability and construct validity of the scorecard. Inter-rater reliability using inter-class correlation (ICC) (1, k) was assessed with one-way ANOVA. Exploratory factor analysis (EFA) was conducted to assess the construct validity, and an updated factor structure were developed.Results32 indicators and 6 management practice domains were initially described. Ordinal responses were derived for each indicator. Data on the scorecard were obtained from 111 PHC facilities. The ICC of mean ratings for each team of judges was 0.94. The EFA identified 6 domains (Stakeholder engagement and communication; Community-level activities; Update of plan and target; Performance management; Staff attention to planning, target, and performance; and Drugs and financial management) and reduced the number of indicators to 17. The average communality of selected items was 0.45, and item per factor ratio was 17:6.ConclusionsDespite a few areas for further refinement, this paper presents a reliable and valid scorecard for measuring management practices in PHC facilities. The scorecard can be applied for routine supervisory visits to PHC facilities, and can help accumulate knowledge on facility management, how it affects performance, and how it may be strengthened.

Sustaining economic activities while curbing the number of new coronavirus disease 2019 (COVID-19) cases until effective vaccines or treatments become available is a major public health and policy challenge. In this paper, we use agent-based simulations of a network-based susceptible-exposed-infectious-recovered (SEIR) model to investigate two network intervention strategies for mitigating the spread of transmission while maintaining economic activities. In the simulations, we assume that people engage in group activities in multiple sectors (e.g., going to work, going to a local grocery store), where they interact with others in the same group and potentially become infected. In the first strategy, each group is divided into two subgroups (e.g., a group of customers can only go to the grocery store in the morning, while another separate group of customers can only go in the afternoon). In the second strategy, we balance the number of group members across different groups within the same sector (e.g., every grocery store has the same number of customers). The simulation results show that the dividing groups strategy substantially reduces transmission, and the joint implementation of the two strategies could effectively bring the spread of transmission under control (i.e., effective reproduction number ≈ 1.0).

High-need, high-cost (HNHC) patients-usually defined as those who account for the top 5% of annual healthcare costs-use as much as half of the total healthcare costs. Accurately predicting future HNHC patients and designing targeted interventions for them has the potential to effectively control rapidly growing healthcare expenditures. To achieve this goal, we used a nationally representative random sample of the working-age population who underwent a screening program in Japan in 2013-2016, and developed five machine-learning-based prediction models for HNHC patients in the subsequent year. Predictors include demographics, blood pressure, laboratory tests (e.g., HbA1c, LDL-C, and AST), survey responses (e.g., smoking status, medications, and past medical history), and annual healthcare cost in the prior year. Our prediction models for HNHC patients combining clinical data from the national screening program with claims data showed a c-statistics of 0.84 (95%CI, 0.83-0.86), and overperformed traditional prediction models relying only on claims data.

BackgroundAs the U.S. homeless population grows, so has the challenge of providing effective care to homeless individuals. Understanding hospitals that achieve better outcomes after hospital discharge for homeless patients has important implications for making our health system more sustainable and equitable.ObjectiveTo determine whether homeless patients experience higher rates of readmissions and emergency department (ED) visits after hospital discharge than non-homeless patients, and whether the homeless patients exhibit lower rates of readmissions and ED visits after hospital discharge when they were admitted to hospitals experienced with the treatment of the homeless patients ("homeless-serving" hospitals-defined as hospitals in the top decile of the proportion of homeless patients).DesignA population-based longitudinal study, using the data including all hospital admissions and ED visits in FL, MA, MD, and NY in 2014.ParticipantsParticipants were 3,527,383 patients (median age [IQR]: 63 [49-77] years; 1,876,466 [53%] women; 134,755 [4%] homeless patients) discharged from 474 hospitals.Main measuresRisk-adjusted rates of 30-day all-cause readmissions and ED visits after hospital discharge.Key resultsAfter adjusting for potential confounders, homeless patients had higher rates of readmissions (adjusted rate, 27.3% vs. 17.5%; adjusted odds ratio [aOR], 1.93; 95% CI, 1.69-2.21; p < 0.001) and ED visits after hospital discharge (37.1% vs. 23.6%; aOR, 1.98; 95% CI, 1.74-2.25; p < 0.001) compared with non-homeless patients. Homeless patients treated at homeless-serving hospitals exhibited lower rates of readmissions (23.9% vs. 33.4%; p < 0.001) and ED visits (31.4% vs. 45.4%; p < 0.001) after hospital discharge than homeless patients treated at non-homeless-serving hospitals.ConclusionsHomeless patients were more likely to be readmitted or return to ED within 30 days after hospital discharge, especially when they were treated at hospitals that treat a small proportion of homeless patients. These findings suggest that homeless patients may receive better discharge planning and care coordination when treated at hospitals experienced with caring for homeless people.

BackgroundEvidence is limited and mixed as to how the Patient Protection and Affordable Care Act (ACA) Medicaid expansions affected the utilization of primary care physicians (PCPs) and emergency departments (EDs) at the national level.ObjectiveTo examine the association between the ACA Medicaid expansions and changes in the utilization of PCP and ED visits at the national level during the first 3 years (2014-2016) of the implementation.DesignA difference-in-differences analysis to compare outcomes between individuals in 32 states that expanded Medicaid versus individuals in 19 non-expansion states.ParticipantsA nationally representative sample of US-born individuals 26-64 years old with family incomes lower than 138% of the federal poverty level from the 2010-2016 Medical Expenditure Panel Survey.InterventionACA Medicaid expansions MAIN MEASURES: We examined PCP-related outcomes ((i) whether a participant had any PCP visit during a year and (ii) the annual number of PCP visits per person) and ED-related outcomes ((i) whether a participant had any ED visit during a year and (ii) the annual number of ED visits per person).Key resultsA total of 17,803 participants were included in our analysis. We found that the proportion of individuals with any PCP visit during a year marginally increased (difference-in-differences estimate, + 3.6 percentage points [pp]; 95% CI, - 0.4 pp to + 7.6 pp; P = 0.08) following the Medicaid expansions, without any change in the annual number of PCP visits per person. We found no evidence that ED utilization (both the proportion of individuals with any ED visit during a year and the annual number of ED visits per person) changed meaningfully after the Medicaid expansions.ConclusionUsing the nationally representative data of individuals who were affected by the ACA, we found that the ACA Medicaid expansions were associated with a modest improvement in access to PCPs without an increase in ED use.

OBJECTIVE:To examine the association between expansion of the Medicaid program under the Affordable Care Act and changes in healthcare spending among low income adults during the first four years of the policy implementation (2014-17). DESIGN:Quasi-experimental difference-in-difference analysis to examine out-of-pocket spending and financial burden among low income adults after Medicaid expansions. SETTING:United States. PARTICIPANTS:A nationally representative sample of individuals aged 19-64 years, with family incomes below 138% of the federal poverty level, from the 2010-17 Medical Expenditure Panel Survey. MAIN OUTCOMES AND MEASURES:Four annual healthcare spending outcomes: out-of-pocket spending; premium contributions; out-of-pocket plus premium spending; and catastrophic financial burden (defined as out-of-pocket plus premium spending exceeding 40% of post-subsistence income). P values were adjusted for multiple comparisons. RESULTS:37 819 adults were included in the study. Healthcare spending did not change in the first two years, but Medicaid expansions were associated with lower out-of-pocket spending (adjusted percentage change -28.0% (95% confidence interval -38.4% to -15.8%); adjusted absolute change -$122 (£93; €110); adjusted P

BackgroundAlthough homelessness and opioid overdose are major public health issues in the U.S., evidence is limited as to whether homelessness is associated with an increased risk of opioid overdose.ObjectiveTo compare opioid-related outcomes between homeless versus housed individuals in low-income communities.Design, setting, and participantsCross-sectional analysis of individuals who had at least one ED visit or hospitalization in four states (Florida, Maryland, Massachusetts, and New York) in 2014.MeasurementsRisk of opioid overdose and opioid-related ED visits/hospital admissions were compared between homeless versus low-income housed individuals, adjusting for patient characteristics and hospital-specific fixed effects (effectively comparing homeless versus low-income housed individuals treated at the same hospital). We also examined whether risk of opioid-related outcomes varied by patients' sex and race/ethnicity.ResultsA total of 96,099 homeless and 2,869,230 low-income housed individuals were analyzed. Homeless individuals had significantly higher risk of opioid overdose (adjusted risk, 1.8% for homeless vs. 0.3% for low-income housed individuals; adjusted risk difference [aRD], +1.5%; 95%CI, +1.0% to +2.0%; p