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Objectives Confounding factors, including sex, age, and renal dysfunction, affect high-sensitivity cardiac troponin T (hs-cTnT) concentrations and the acute myocardial infarction (AMI) diagnosis. This study assessed the effects of these confounders through logistic regression models and evaluated the diagnostic performance of an optimized, integrated prediction model. Methods This retrospective study included a primary derivation cohort of 18,022 emergency department (ED) patients at a US medical center and a validation cohort of 890 ED patients at a Canadian medical center. Hs-cTnT was measured with 0/3 h sampling. The primary outcome was index AMI diagnosis. Logistic regression models were optimized to predict AMI using delta hs-cTnT and its confounders as covariates. The diagnostic performance of model cutoffs was compared to that of the hs-cTnT delta thresholds. Serial logistic regressions were carried out to evaluate the relationship between covariates. Results The area under the curve of the best-fitted model was 0.95. The model achieved a 90.0% diagnostic accuracy in the validation cohort. The optimal model cutoff yielded comparable performance (90.5% accuracy) to the optimal sex-specific delta thresholds (90.3% accuracy), with 95.8% agreement between the two diagnostic methods. Serial logistic regressions revealed that delta hs-cTnT played a more predominant role in AMI prediction than its confounders, among which sex is more predictive of AMI (total effect coefficient 1.04) than age (total effect coefficient 0.05) and eGFR (total effect coefficient −0.008). Conclusions The integrated prediction model incorporating confounding factors does not outperform hs-cTnT delta thresholds. Sex-specific hs-cTnT delta thresholds remain to provide the highest diagnostic accuracy.

Objectives:To evaluate trends in racial and ethnic disparities in weekly cumulative rates of coronavirus disease 2019 (COVID-19) cases and deaths in Connecticut nursing homes.Design:Longitudinal analysis of nursing-home COVID-19 reports and other databases. Multivariable negative binomial models were used to estimate disparities in COVID-19 incidence and fatality rates across nursing-home groups with varying proportions of racial and ethnic minority residents, defined as low-, medium-, medium-high-, and high-proportion groups. Trends in such disparities were estimated from week 1 (April 13) to week 10 (ending on June 19, 2020).Setting:The study was conducted across 211 nursing homes.Results:The average number of cases ranged from 6.1 cases per facility for the low-proportion group to 11.7 cases per facility for the high-proportion group in week 1, and from 26.7 to 58.5 cases per facility in week 10. Compared to the low-proportion group, the adjusted incidence rate ratios (IRRs) for the high-proportion group were 1.18 (95% confidence interval [CI], 0.77–1.80; P > .10) in week 1 and 1.54 (95% CI, 1.05–2.25; P < .05) in week 10, showing a 30% (95% CI, 5%–62%) relative increase (P < .05). The average weekly number of COVID-19–related deaths ranged from 0 to 0.3 deaths per facility for different groups in week 1, and from 7.6 to 13.3 deaths per facility in week 10. Adjusted disparities in fatalities similarly increased over time.Conclusions:Connecticut nursing homes caring for predominately racial and ethnic minority residents tended to have higher COVID-19 incidence and fatality rates. These across-facility disparities increased during the early periods of the pandemic.

The purpose of this pilot study was to assess the immediate impact of vaping prevention graphic messages on the susceptibility to future vaping among Black and Latino adolescents (ages 12 to 17). Graphic messages (available in English and Spanish) were developed using participatory research procedures with Black and Latino adolescents. Recruitment was conducted by a team of diverse, bilingual (English and Spanish), trained recruiters. Participants (n = 362) were randomized in a 1:1:1:1 schema to receive one of four graphic messages (health rewards, financial rewards, autonomy, and social norms). Overall, all graphic messages but one showed a slight decrease in the number of participants susceptible to future vaping, though none of these differences was statistically significant. The graphic message on health rewards decreased the number of participants susceptible to future vaping the most (55.7% vs. 50%, at pre- vs. post-viewing, p = 0.125), followed by the graphic messages on social norms and autonomy (55.1% vs. 52.8%, p = 0.687; 55.4% vs. 52.2%, p = 0.435; respectively). The graphic message on financial rewards increased the number of participants susceptible to future vaping slightly (52.7% vs. 53.8%, p = 1.00). Future research is needed to evaluate susceptibility to future vaping before and after exposure to different and/or repeated vaping prevention graphic messages.

IMPORTANCE: The Medicare Comprehensive Care for Joint Replacement (CJR) model, a mandatory bundled-payment program started in April 2016 for hospitals in randomly selected Metropolitan Statistical Areas (MSAs), may help reduce post-acute care (PAC) use and episode costs, but its impact on disparities between Medicaid and non-Medicaid beneficiaries is unknown. OBJECTIVE: To determine effects of the CJR program on differences (or disparities) in PAC use and outcomes by Medicare-Medicaid dual eligibility status. DESIGN, SETTING, AND PARTICIPANTS: Observational cohort study of 2013–17, based on difference-in-differences (DID) analyses on Medicare data for 1,239,452 Medicare-only patients, 57,452 dual eligibles with full Medicaid benefits, and 50,189 dual eligibles with partial Medicaid benefits who underwent hip or knee surgery in hospitals of 75 CJR MSAs and 121 control MSAs. MAIN OUTCOME MEASURES: Risk-adjusted differences in rates of institutional PAC (skilled nursing facility [SNF], inpatient rehabilitation, or long-term hospital care) use and readmissions; and for the subgroup of patients discharged to SNF, risk-adjusted differences in SNF length of stay, payments, and quality measured by star ratings, rate of successful discharge to community, and rate of transition to long-stay nursing home resident. RESULTS: The CJR program was associated with reduced institutional PAC use and readmissions for patients in all 3 groups. For example, it was associated with reductions in 90-day readmission rate by 1.8 percentage-point (DID-estimate=−1.8, 95% confidence interval [CI] −2.6 to −0.9, p

OBJECTIVE To describe variations in COVID-19 confirmed cases and deaths among assisted living (AL) residents and examine their associations with key AL characteristics. DESIGN Observational study employing data on confirmed COVID-19 cases and deaths in ALs from seven states, through May 29, 2020. SETTING Information on COVID-19 cases/deaths in ALs was obtained from state government websites. A national inventory of ALs was used to identify communities with and without COVID-19 cases/deaths. Medicare Beneficiary Summary File identifying AL residents was employed to develop AL characteristics. County-level COVID-19 laboratory-confirmed cases/deaths were obtained from publicly available data. PARTICIPANTS We found 4,865 ALs (2,647 COVID-19 cases and 777 deaths) in the seven states. After excluding missing data, the sample consisted of 3,994 ALs (82.1%) with 2,542 cases (96.0%) and 675 deaths (86.9%). MAIN OUTCOMES AND MEASURES Outcomes were AL-level counts of cases and deaths. Covariates were AL characteristics and county-level confirmed COVID-19 cases/deaths. Multivariable two-part models determined the associations of independent variables with the likelihood of at least one case and death in the AL, and with the count of cases (deaths). RESULTS State case fatality ranged from 3.32% in North Carolina to 9.26% in Connecticut, but for ALs in these states it was 12.89% and 31.59%, respectively. Among ALs with at least one case, midsize communities had fewer cases (incidence rate ratio (IRR) = 0.829; P = .004) than small ALs. ALs with higher proportions of racial/ethnic minorities had more COVID-19 cases (IRR = 1.08; P

Background Several trends suggest that the nurse practitioner (NP) workforce has untapped potential to expand healthcare capacity to increase access to care. Purpose The aim of this study was to examine NPs as usual source of care providers and investigate their relationship with state scope-of-practice (SOP) regulations. Methods A retrospective analysis was performed using data from the Medical Expenditure Panel Survey on a sample of U.S. adults from 2010 to 2016. Results Modest growth in the proportion of U.S. adults who self-reported having an NP as their usual source of care provider was found from 2010 to 2016. Despite this growth, the national average of the percentage of adults with an NP as their usual source of care provider remained small. Full SOP regulation was shown to be associated with increased odds of having an NP as a usual source of care provider. In particular, adults who were on public health insurance, uninsured, and resided in nonmetropolitan areas benefited from having an NP as a usual source of care provider. Conclusion Our study provides empirical evidence on the link between full SOP regulation and increased odds of having an NP as a usual source of care provider.

Background/objectives To determine racial/ethnic disparities in weekly counts of new COVID-19 cases and deaths among nursing home residents or staff. Design Cross-sectional analysis of national nursing home COVID-19 reports linked to other data. Multivariable two-part models modeled disparities in count of cases or deaths, and logistic regressions modeled disparities in self-reported shortages in staff and personal protective equipment (PPE), across nursing home groups with varying proportions of racial/ethnic minority residents, defined as low-, medium-, medium-high-, and high-proportion groups. Setting A total of 12,576 nursing homes nationally. Participants None. Intervention None. Measurements Numbers of incident COVID-19 confirmed cases among residents and staff, and incident COVID-19 related deaths among residents (primary outcomes); and nursing home reported shortages in staff and PPE (secondary outcomes). All outcomes were reported for the week of May 25, 2020. Results The number of weekly new COVID-19 confirmed cases among residents ranged from an average of 0.4 cases per facility (standard deviation (SD) = 2.5) for the low-proportion group (93.0% had zero new cases) to 1.5 cases per facility (SD = 6.3) for the high-proportion group (78.9% had zero new cases). Multivariable regression estimated that compared with the low-proportion group, the likelihood of having at least one new resident case was 76% higher (odds ratio = 1.76; 95% confidence interval = 1.38-2.25; P = .000) for the high-proportion group. Similar across-facility disparities were found for the weekly count of new COVID-19 deaths among residents (ranging from 0.1 deaths per facility (SD = 1.1) for the low-proportion group to 0.4 deaths (SD = 2.0) for the high-proportion group) and in the weekly count of new COVID-19 confirmed cases among staff (ranging from 0.3 cases (SD = 1.4] to 1.3 cases (SD = 4.4) per facility). No substantial disparities in self-reported shortages of staff or PPE were found. Conclusion Nursing homes caring for disproportionately more racial/ethnic minority residents reported more weekly new COVID-19 confirmed cases and/or deaths. Immediate actions are needed to address these system-level disparities.

High-sensitivity cardiac troponin (hs-cTn) plays an essential role in facilitating the diagnosis of acute myocardial infarction (AMI). However, there are several known confounding factors affecting hs-cTn concentrations, including sex, age and renal dysfunction. Women have significantly lower hs-cTn concentrations compared to men in presumably healthy populations and in patients presenting to the emergency department (ED). Increasing age leads to elevated troponin levels; and decreasing estimated glomerular filtration rate (eGFR) associates with higher troponin concentrations. How to interpret hs-cTn results in the presence of these confounding factors remains an open question. The aim of this study is to assess whether an integrated prediction model that incorporates hs-cTnT and its confounding factors performs better than hs-cTnT delta threshold alone and to delineate the effect of each confounding factor on the AMI diagnosis. This retrospective cohort study included 17,842 ED patients with serial hs-cTnT measured using a 0h/3h algorithm and eGFR calculated by CKD-EPI creatinine equation at a US medical center. The primary outcome was AMI diagnosis at discharge. Model selection was performed using the logistic regression models of AMI diagnosis with hs-cTnT absolute delta changes and different sets of covariates, which included age, sex, eGFR, and time delta. Model with the smallest Aikaike Information Criteria (AIC) was chosen as the final model, and two-fold cross validation was performed to evaluate model goodness of fit. The area under curve (AUC) of the best fitted model was 0.95. Empirical receiving operating characteristics analysis derived the best probability cutoff of 0.03 for AMI prediction based on a 90% specificity benchmark. The diagnostic performance of this cutoff was compared to that of the hs-cTnT 0h/3h sex-specific delta thresholds we published earlier. The agreement between the prediction model cutoff and the sex-specific delta thresholds was 95.8% (Kappa coefficient 0.80). The agreement to true diagnosis was comparable with hs-cTnT sex-specific delta thresholds alone (90.3% agreement, Kappa coefficient 0.32) and with the prediction model cutoff (90.5% agreement, Kappa coefficient 0.33). To further delineate the effects of the confounders, mediation analysis and spearman correlation analysis showed that hs-cTnT delta change has a much stronger correlation with AMI diagnosis than its confounders. Among the confounders, sex is more predictive of AMI diagnosis (logistic coefficient 0.53) than age (logistic coefficient 0.02) and eGFR (logistic coefficient 0.02). While most of the effects of age and sex on AMI were mediated through delta troponin, the effect of eGFR on AMI diagnosis was almost entirely canceled by mediation through troponin. In summary, the confounding factors play a weaker role than hs-cTn delta change in AMI diagnosis. The integrated prediction model incorporating all confounding factors does not perform better than hs-cTnT delta threshold alone. Sex-specific hs-cTnT delta thresholds remain to yield the highest diagnostic accuracy.

Introduction: Smoking menthol cigarettes is more prevalent among Latinos compared to non-Latino Whites. Latinos who smoke menthol are less likely to quit than Latinos who do not smoke menthol. However, there is scant information on the biopsychosocial factors correlated with smoking menthol among Latinos. Objective: To assess the biopsychosocial correlates of smoking menthol cigarettes and whether smoking menthol is associated with cessation among Latino smokers. Methods: This secondary analysis utilized baseline data from the Decídetexto study, an mhealth smoking cessation randomized clinical trial for Latinos. Participants resided in the United States and originated from the U.S. and 20 Latin American countries. Biopsychosocial variables included body mass index, # of comorbidities, age, alcohol use, depression, anxiety, self-efficacy, education, health insurance, household income, marital status, country of origin, and acculturation – years in the U.S., primary language, and generation, and smoking cessation. Chi-square tests and one-way ANOVAs were employed. Logistic regression models were performed to test the association between menthol use and smoking cessation, when treatment arm and other demographic variables were controlled. Results: Participants’ (n=457) mean age was 48.7 (SD=11.1), most were female (54.7%), primarily Spanish speakers (70.5%), daily smokers (91.7%), married (53.6%), and had an annual income between 0 – 29K (42.7%). Almost half of participants currently smoke menthol cigarettes (48.8%) and mean daily cigarettes was 11.6 (SD=8.03). Use of menthol was associated positively with younger age (46.3 vs 51.0 years; p Citation Format: Evelyn Arana-Chicas, Francisco Cartujano-Barrera, Xueya Cai, Shan Gao, Lisa S. Cox, Ana P. Cupertino. Biopsychosocial correlates of smoking menthol cigarettes and cessation among Latino smokers [abstract]. In: Proceedings of the 15th AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2022 Sep 16-19; Philadelphia, PA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2022;31(1 Suppl):Abstract nr B001.

The COVID-19 pandemic has both elucidated and exacerbated racial and ethnic disparities in the United States. Conspicuous early effects in healthcare access and direct morbidity and mortality due to COVID-19 disease revealed that, compared to White populations, Black and Hispanic communities suffered greater rates of mortality,1,2 especially among older adults.3 Preliminary findings also suggest that Black and Hispanic adults were more vulnerable to income instability and food insecurity during the pandemic.4 This study examined racial and ethnic disparities in household finances during the early period of the pandemic. Using data from a nationally representative survey, we tested the hypotheses that Black and Hispanic older adults experienced reduced income and increased household spending in the first 3 months of the pandemic.

Background Little is known about the impact of the U.S. Centers for Medicare & Medicaid Services' Hospital Readmissions Reduction Program (HRRP) expansion to include readmissions following elective primary total hip and knee replacements; the expansion was finalized in 2013 and was implemented in 2014. We examined whether hospitals at risk of relatively large penalties from this expansion experienced greater declines in joint replacement readmissions compared with hospitals at risk of smaller penalties. Methods We used Medicare's 2009 to 2016 Hospital Compare data sets to examine the impact of the HRRP's expansion in the July 2013 to June 2016 period (post-expansion) compared with the July 2009 to June 2012 period (pre-expansion). The primary outcome was the hospital-level, 30-day, risk-standardized readmission rate (hereafter called the readmission rate) following joint replacement surgical procedures. We used the percentage of a hospital's total inpatient revenue attributed to Medicare (categorized into quartiles) to represent the risk of penalties. We used hierarchical linear regression models to examine the adjusted impact of the HRRP's expansion. Results Our study cohort included 2,326 acute care hospitals. In the pre-HRRP expansion phase, the mean readmission rate was 5.36% among hospitals with the highest proportion of Medicare revenues (quartile 4) and 5.46% among hospitals with the lowest proportion of Medicare revenues (quartile 1). With the HRRP expansion, the readmission rate declined by 18.92% (1.01 percentage points) among quartile-4 hospitals and by 17.97% (0.98 percentage point) among quartile-1 hospitals (p = 0.45). This nonsignificant difference in readmission rate declines between quartiles persisted in multivariable analysis (a decline of 18.41% [0.98 percentage point] in quartile 4 and a decline of 17.35% [0.94 percentage point] in quartile 1; p = 0.35). Conclusions The HRRP's expansion to include joint replacements did not lead to greater reductions in postoperative readmissions among hospitals at risk of larger penalties in comparison with hospitals at risk of smaller penalties. Readmission rates were declining at similar rates among all hospitals, before and after the HRRP's expansion. Clinical relevance Readmissions and complications following joint replacements are measures of the quality of surgical care. These events have important clinical and economic implications for patients and providers. This study is clinically relevant because it examines whether policy interventions, such as the HRRP, have the potential to reduce these unintended consequences of surgical care.

BACKGROUND: The safety and quality of care provided to nursing home residents is a significant concern. Little is unknown whether fostering patient safety culture helps improve the safety and quality of nursing home care. METHODS: This study determined the associations of nursing home patient safety culture performance, as reported by administrators, directors of nursing, and unit leaders in a large national sample of free-standing nursing homes, with several “Nursing Home Compare” (NHC) performance indicators. We conducted a survey in 2017 using the Agency for Healthcare Research and Quality (AHRQ) Survey on Patient Safety Culture™ (SOPS™) for nursing homes to collect data on 12 core domains of safety culture scores. Survey data were linked to other nursing home files for multivariable regression analyses. RESULTS: Overall, 818 out of the 2254 sampled nursing homes had at least one completed survey returned for a response rate of 36%. After adjustment for nursing home, market, and state covariates, every 10 percentage points increase in overall positive response rate for safety culture was associated with 0.56 fewer healthcare deficiencies (p=0.001), 0.74 fewer substantiated complaints (p=0.004), reduced fines by $2285.20 (p=0.059), and 20% increased odds of being designated as 4- or 5-star (vs. 1–3 star) facilities (odds ratio roughly 1.20, p

To examine the relationship between loneliness and self-reported delay or avoidance of medical care among community-dwelling older adults during the coronavirus disease 2019 (COVID-19) pandemic.Analyses of data from a nationally representative survey administered in June of 2020, in COVID-19 module of the Health and Retirement Study. Bivariate and multivariable analyses determined associations of loneliness with the likelihood of, reasons for, and types of care delay or avoidance.The rate of care delay or avoidance since March of 2020 was 29.1% among all respondents (n = 1997), and 10.1% higher for lonely (n = 1,150%, 57.6%) versus non-lonely respondents (33.5% vs. 23.4%; odds ratio = 1.59, p = 0.003 after covariate adjustment). The differences were considerably larger among several subgroups such as those with emotional/psychiatric problems. Lonely older adults were more likely to cite "Decided it could wait," "Was afraid to go," and "Couldn't afford it" as reasons for delayed or avoided care. Both groups reported dental care and doctor's visit as the two most common care delayed or avoided.Loneliness is associated with a higher likelihood of delaying or avoiding medical care among older adults during the pandemic.

Confirmation of effectiveness of asthma biologics in the real world is desirable because patient characteristics and experiences may differ from those included in randomized controlled trials.To evaluate real-world effectiveness of asthma biologics and identify predictors of response.We performed a retrospective study in patients with severe asthma receiving biologics. The primary outcome was change in clinically significant exacerbations at 12 months after starting biologic therapy, compared with 12 months before. Secondary outcomes were change in severe exacerbations, maintenance oral corticosteroid (OCS) dose, prebronchodilator forced expiratory volume in 1 second (FEV1), and asthma control test scores. Subgroup analyses were performed for subjects who were biologic naive or not. A stepwise logistic regression model was performed to compare responders to nonresponders.A total of 112 patients were included. Biologic therapy was associated with a 59% reduction in clinically significant exacerbations (P.001), 65% reduction in severe exacerbations (P.001), and 54% reduction in maintenance OCS dose (P = .001) in the 12 months after starting therapy. Biologics also resulted in improvement in prebronchodilator FEV1 (P = .002) and Asthma Control Test score (P.001). Subjects who were previously on another biologic also experienced significant improvements in exacerbation frequency, maintenance OCS dose, and asthma control. Responders were more likely to be nonsmokers and have higher baseline FEV1, gastroesophageal reflux disease, and eosinophil counts greater than 500 cells/μL.In a real-world setting, biologic therapy in asthma is effective in improving exacerbations, asthma control, and lung function. Patients who have a suboptimal response to 1 biologic can still benefit from treatment with a different biologic.

Background Sex differences in high-sensitivity cardiac troponin (hs-cTn) concentrations from healthy populations have led to the establishment of sex-specific upper reference limits for hs-cTn assays. This study assessed the performance of sex-specific delta (i.e., changes in concentrations) thresholds for the hs-cTnT assay for ruling in acute myocardial infarction (AMI) in different emergency department (ED) populations. Methods This retrospective study consisted of 2 cohorts (Cohort 1 derivation and Cohort 2 validation). Cohort 1 consisted of 18 056 ED patients who had serial hs-cTnT measured using a 0-h/3-h algorithm at a US medical center, with Cohort 2 consisting of 1137 ED patients with 0-h/3-h sampling at a Canadian medical center. The primary outcome was AMI diagnosis with sex-specific deltas derived based on the Youden index and specificity estimates (i.e., ≥90%) in Cohort 1 and validated in Cohort 2. Results In Cohort 1, 42% of all patients had 0-h hs-cTnT above the sex-specific 99th percentile. Males had higher 0-h hs-cTnT (median 17 ng/L) and absolute deltas (median 2 ng/L) than females (0-h median 11 ng/L, P Conclusions Sex-specific absolute delta thresholds can be used to rule in AMI and are robust across different study populations.

This cohort study evaluates whether the implementation of a large-scale Medicare policy is associated with unequal use of and access to joint replacement care among older adults from various racial/ethnic groups and socioeconomic backgrounds., Key Points Question Is the Comprehensive Care for Joint Replacement (CJR) model associated with worsening of racial/ethnic and socioeconomic disparities in total hip replacement or total knee replacement use among older Medicare beneficiaries? Findings In this cohort study of 4 447 205 Medicare beneficiaries, the CJR model was associated with an increase in total knee replacement use for non-Hispanic White beneficiaries and a decrease for non-Hispanic Black beneficiaries. The CJR model was also associated with widening of the gap in total knee replacement use among non-Hispanic White beneficiaries with non–dual eligibility for Medicaid compared with non-Hispanic Black beneficiaries with either non–dual eligibility or dual eligibility; no such widening of the gap was found for total hip replacement use. Meaning The study found that the CJR model was associated with modest worsening of racial/ethnic and socioeconomic disparities in total knee replacement use, highlighting the need for payment reforms that incentivize the reduction of disparities., Importance The Comprehensive Care for Joint Replacement (CJR) model is Medicare’s mandatory bundled payment reform to improve quality and spending for beneficiaries who need total hip replacement (THR) or total knee replacement (TKR), yet it does not account for sociodemographic risk factors such as race/ethnicity and income. Results of this study could be the basis for a Medicare payment reform that addresses inequities in joint replacement care. Objective To examine the association of the CJR model with racial/ethnic and socioeconomic disparities in the use of elective THR and TKR among older Medicare beneficiaries after accounting for the population of patients who were at risk or eligible for these surgical procedures. Design, Setting, and Participants This cohort study used the 2013 to 2017 national Medicare data and multivariable logistic regressions with triple-differences estimation. Medicare beneficiaries who were aged 65 to 99 years, entitled to Medicare, alive at the end of the calendar year, and residing either in the 67 metropolitan statistical areas (MSAs) mandated to participate in the CJR model or in the 104 control MSAs were identified. A subset of Medicare beneficiaries with a diagnosis of arthritis underwent THR or TKR. Data were analyzed from March to December 2020. Exposures Implementation of the CJR model in 2016. Main Outcomes and Measures Outcomes were separate binary indicators for whether a beneficiary underwent THR or TKR. Key independent variables were MSA treatment status, pre- or post-CJR model implementation phase, combination of race/ethnicity (non-Hispanic White, non-Hispanic Black, and Hispanic beneficiaries) and dual eligibility, and their interactions. Logistic regression models were used to control for patient characteristics, MSA fixed effects, and time trends. Results The 2013 cohort included 4 447 205 Medicare beneficiaries, of which 2 025 357 (45.5%) resided in MSAs with the CJR model. The cohort’s mean (SD) age was 77.18 (7.95) years, and it was composed of 2 951 140 female (66.4%), 3 928 432 non-Hispanic White (88.3%), and 657 073 dually eligible (14.8%) beneficiaries. Before the CJR model implementation, rates were highest among non-Hispanic White non–dual-eligible beneficiaries at 1.25% (95% CI, 1.24%-1.26%) for THR use and 2.28% (95% CI, 2.26%-2.29%) for TKR use in MSAs with CJR model. Compared with MSAs without the CJR model and the analogous race/ethnicity and dual-eligibility group, the CJR model was associated with a 0.10 (95% CI, 0.05-0.15; P

The COVID-19 poses a disproportionate threat to nursing home residents. Although recent studies suggested the effectiveness of state social distancing measures in the United States on curbing COVID-19 morbidity and mortality among the general population, there is lack of evidence as to how these state orders may have affected nursing home patients or what potential negative health consequences they may have had. In this longitudinal study, we evaluated changes in state strength of social distancing restrictions from June to August of 2020, and their associations with the weekly numbers of new COVID-19 cases, new COVID-19 deaths, and new non–COVID-19 deaths in nursing homes of the US. We found that stronger state social distancing measures were associated with improved COVID-19 outcomes (case and death rates), reduced across-facility disparities in COVID-19 outcomes, but more deaths due to non–COVID-19 reasons among nursing home residents.

Background The age-based multiplier method described by Paley et al. markedly simplifies height and limb length predictions but may not adequately accommodate children's maturational differences. Multipliers can be derived relative to any maturity measure. This study compares Paley age-based multipliers with those based on peak height velocity (PHV) timing. Methods In a longitudinal cohort of healthy children (66 male and 70 female), actual adult heights and limb lengths were compared with the measurements predicted using the Paley multipliers and multipliers developed relative to PHV timing. The age-based multipliers (adult divided by current) in our series were compared with those reported by Paley et al. to ensure that there were no systematic differences between the series. Absolute differences between the actual and predicted adult heights and limb lengths and the standard deviations of those differences were compared between the 2 methods. Results The average age-based multipliers in our series were nearly identical to those reported by Paley et al. The differences between the predicted and actual adult values showed wide ranges when either the Paley or the PHV multipliers were used during infancy. The Paley method performed better than the PHV method throughout pre-growth-spurt childhood. The PHV-timing-derived multipliers became superior as children entered their growth spurt, whereas the performance of the age-based multipliers worsened. In adolescence, the maximum standard deviation for adult-height-prediction errors with use of the Paley multipliers occurred at the age of 13.5 years for boys and 11.5 years for girls and was 7.0 cm for boys and 5.6 cm for girls. For limb lengths, the maximum standard deviations occurred 6 months earlier and were 3.9 cm for boys and 3.2 cm for girls. The maximum standard deviation for the height prediction error with the age-based method occurred at the average time of PHV for the population. The PHV method became better than the Paley method just before growth-spurt initiation, at age 8 in girls and 11 in boys. Conclusions The age-based multipliers described by Paley et al. are superior to PHV-timing-based multipliers prior to the adolescent growth spurt for predicting height. They become less predictive, with wide standard deviations, as children enter their growth spurts, and PHV-derived multipliers become superior. The Paley height multipliers should be used before the age of 8 years in girls and 11 years in boys. After this, PHV-derived multipliers are superior for height and limb length prediction. In practice, these predictions are currently made using skeletal maturity, which is closely related to PHV during adolescence.

BACKGROUND Little is known about how the geographic variation and disparities in use of elective primary total hip and knee replacements for Medicare beneficiaries have evolved in recent years. The study objectives are to determine these variations and disparities, whether Black Medicare beneficiaries have continued to undergo fewer total hip replacements and total knee replacements across regions, and whether disparities affected all Black beneficiaries or mainly affected socioeconomically disadvantaged Black beneficiaries. METHODS We used 2009 to 2017 Medicare enrollment and claims data to examine Hospital Referral Region (HRR)-level variation and disparities by race (non-Hispanic White and Black) and socioeconomic status (Medicare-only and dual eligibility for both Medicare and Medicaid). The outcomes were HRR-level age and sex-standardized total hip replacement and total knee replacement utilization rates for White Medicare-only beneficiaries, White dual-eligible beneficiaries, Black Medicare-only beneficiaries, and Black dual-eligible beneficiaries, and the differences in rates between these groups as a representation of disparities. The key exposure variables were race-socioeconomic group and year. We constructed multilevel mixed-effects linear regression models to estimate trends in total hip replacement and total knee replacement rates and to examine whether rates were lower in HRRs with high percentages of Black beneficiaries or dual-eligible beneficiaries. RESULTS The study included 924,844 total hip replacements and 2,075,968 total knee replacements. In 2017, the mean HRR-level total hip replacement rate was 4.64 surgical procedures per 1,000 beneficiaries, and the mean HRR-level total knee replacement rate was 9.66 surgical procedures per 1,000 beneficiaries, with a threefold variation across HRRs. In 2017, the total hip replacement rate was 32% higher for White Medicare-only beneficiaries and 48% higher for Black Medicare-only beneficiaries than in 2009 (p < 0.001). However, because the surgical rates for White and Black dual-eligible beneficiaries remained unchanged over the study period, the 2017 Medicare-only and dual-eligible disparity for White beneficiaries increased by 0.75 surgical procedures per 1,000 from 2009 (40.98% increase; p = 0.03), and the disparity for Black beneficiaries by 1.13 surgical procedures per 1,000 beneficiaries (297.37% increase; p < 0.001). The total knee replacement disparities remained unchanged. Notably, the rates for White dual-eligible beneficiaries were significantly lower than those for Black Medicare-only beneficiaries (p < 0.001 for both total hip replacements and total knee replacements), and fewer surgical procedures were conducted in HRRs with a higher density of Black or dual-eligible beneficiaries. CONCLUSIONS Although the total hip replacement use for Medicare-only beneficiaries of both races increased, disparities for White and Black dual-eligible beneficiaries (compared with their Medicare-only counterparts) are increasing. Efforts to improve equity must identify and address both racial and socioeconomic barriers and focus on regions with high concentrations of disadvantaged beneficiaries. CLINICAL RELEVANCE Although total hip replacements and total knee replacements are highly successful surgical procedures for end-stage osteoarthritis, our findings show that, as recently as 2017, Black beneficiaries and those dual eligible for Medicaid (a proxy for socioeconomic status) are less likely to undergo these surgical procedures and that there is profound geographic variation in the use of these surgical procedures. This evidence is essential for the design and implementation of disparity-reduction strategies focused on patients, providers, and geographic areas that can potentially improve the equity in joint replacement care.

Lymphocytopenia during the COVID-19 has been associated with fatality. We tested whether pre-existing lymphocytopenia reported prior to any possible exposure to SARS-COV2 (from 2010 to 2019) was associated with fatality. Using all patients diagnosed on testing in a single regional laboratory, we identified 1137 subjects with PCR positive for SARS-COV2 and at least one available complete blood count from the decade prior to any possible exposure to the virus. Bivariate analysis indicated an association between pre-existing lymphocytopenia (defined as absolute lymphocyte count 9 /L) and fatality (18% versus 4%). Furthermore, a logistic regression model, accounting for both patient age and number of blood counts obtained, indicated the subjects with pre-existing lymphocytopenia were 1.4 times as likely to die. Because the absolute lymphocyte count is almost universally available and easily interpreted, this biomarker of the risk of fatality could be widely useful.

RESEARCH OBJECTIVE: Lower extremity joint replacements (LEJR) are among the most common and expensive inpatient surgeries for Medicare beneficiaries. The Comprehensive Care for Joint Replacement (CJR) Model of 2016 is a bundled‐payment initiative for LEJR that was mandated for hospitals in 67 Metropolitan Statistical Areas (MSA) covering the episode of acute and postacute care (PAC). It provides financial incentives for participating hospitals to improve outcomes and reduce episode cost of care. Approximately 30% of LEJR beneficiaries receive institutional PAC (ie, care in skilled nursing facility [SNF], inpatient rehabilitation center, or long‐term hospital) after an inpatient stay. This study aims to determine the impact of CJR on (1) institutional PAC use, readmission rate, and SNF care outcomes for patients discharged to SNFs (the most common type of institutional PAC); and (2) existing gaps in these measures between Medicare‐only and dual‐eligible (Medicare beneficiaries who are also eligible for Medicaid) patients. STUDY DESIGN: We conducted difference‐in‐difference models with MSA sampling weights using Medicare claims and assessment files, and hospital and PAC facility datasets from 2013 to 2017. We compared patient outcomes in hospitals of 75 initially randomly assigned MSAs (participation in CJR mandated) and outcomes of hospitals in 120 control areas. In analyses on all LEJR patients, the outcomes included institutional PAC utilization rate, all‐cause 30‐/90‐day readmission rates, and total payments for readmissions. In analyses on patients discharged to SNF, outcomes included SNF five‐star ratings, rate of successful community discharge, rate of transition to long‐stayers, SNF length of stay (LOS), and SNF total spending. All models adjusted for important patient, facility, and market characteristics. POPULATION STUDIED: 457,472 patients from 763 CJR‐hospitals and 597,764 patients from 924 control hospitals during 2013‐2017. PRINCIPAL FINDINGS: CJR was associated with a 2.35‐percentage‐point (P

To determine the associations of nursing home registered nurse (RN) staffing, overall quality of care, and concentration of Medicaid or racial and ethnic minority residents with 2019 coronavirus disease (COVID-19) confirmed cases and deaths by April 16, 2020, among Connecticut nursing home residents.Cross-sectional analysis on Connecticut nursing home (n = 215) COVID-19 report, linked to other nursing home files and county counts of confirmed cases and deaths. Multivariable two-part models determined the associations of key nursing home characteristics with the likelihood of at least one confirmed case (or death) in the facility, and with the count of cases (deaths) among facilities with at least one confirmed case (death).All Connecticut nursing homes (n = 215).None.None.Numbers of COVID-19 confirmed cases and deaths among residents.The average number of confirmed cases was eight per nursing home (zero in 107 facilities), and the average number of confirmed deaths was 1.7 per nursing home (zero in 131 facilities). Among facilities with at least one confirmed case, every 20-minute increase in RN staffing (per resident day) was associated with 22% fewer confirmed cases (incidence rate ratio [IRR] = .78; 95% confidence interval [CI] = .68-.89; P .001); compared with one- to three-star facilities, four- or five-star facilities had 13% fewer confirmed cases (IRR = .87; 95% CI = .78-.97; P .015), and facilities with high concentration of Medicaid residents (IRR = 1.16; 95% CI = 1.02-1.32; P = .025) or racial/ethnic minority residents (IRR = 1.15; 95% CI = 1.03-1.29; P = .026) had 16% and 15% more confirmed cases, respectively, than their counterparts. Among facilities with at least one death, every 20-minute increase in RN staffing significantly predicted 26% fewer COVID-19 deaths (IRR = .74; 95% CI = I .55-1.00; P = .047). Other focused characteristics did not show statistically significant associations with deaths.Nursing homes with higher RN staffing and quality ratings have the potential to better control the spread of the novel coronavirus and reduce deaths. Nursing homes caring predominantly for Medicaid or racial and ethnic minority residents tend to have more confirmed cases.

PURPOSE: Examine 1) the association between Alzheimer’s disease and related dementias (ADRD) and severe pain in Medicare home health (HH) patients; and 2) the impact of severe pain and ADRD on unplanned facility admissions in this population. DESIGN: Analysis of the Outcome and Assessment Information Set (OASIS) and Medicare claims data of 6,153 patients ≥ 65 years receiving care from a non-profit HH agency in 2017. METHODS: Study outcomes included presence of severe pain and time-to-event measures of unplanned facility admissions (hospital, nursing home, or rehabilitation facilities). ADRD was identified using ICD-10 diagnosis codes and cognitive impairment symptoms. Logistic regression and Cox proportional hazard models were used, respectively, to examine the association between ADRD and severe pain, and the independent and interaction effects of severe pain and ADRD on unplanned facility admission. RESULTS: Patients with ADRD (N=1,525, 24.8%) were less likely to have recorded severe pain than others (16.4% versus 23.6%, p

The Comprehensive Care for Joint Replacement (CJR) model introduced in 2016 aims to improve the quality and costs of care for Medicare beneficiaries undergoing hip and knee replacements. However, there are concerns that the safety-net hospitals that care for the greatest number of vulnerable patients may perform poorly in CJR. In this study we used Medicare's CJR data to evaluate the performance of 792 hospitals mandated to participate in the first year of CJR. We found that in comparison to non-safety-net hospitals, 42 percent fewer safety-net hospitals qualified for rewards based on their quality and spending performance (33 percent of safety-net hospitals qualified, compared to 57 percent of non-safety-net hospitals), and safety-net hospitals' rewards per episode were 39 percent smaller ($456 compared to $743). Continuation of this performance trend could place safety-net hospitals at increased risk of penalties in future years. Medicare and hospital strategies such as those that reward high-quality care for vulnerable patients could enable safety-net hospitals to compete effectively in CJR.

In clinical trials of treatments for chronic pain, the percentage of participants who withdraw early can be as high as 50%. Major reasons for early withdrawal in these studies include perceived lack of efficacy and adverse events. Commonly used strategies for accommodating missing data include last observation carried forward, baseline observation carried forward, and more principled methods such as mixed-model repeated-measures and multiple imputation. All these methods require strong and untestable assumptions concerning the conditional distribution of outcomes after dropout, given the observed data. We review recent developments in statistical methods for handling missing data in clinical trials, including implications of the increased emphasis being placed on precise formulation of the study objectives and the estimand (treatment effect to be estimated) of interest. A flexible method that seems to be well suited for the analysis of chronic pain clinical trials is control-based imputation, which allows a variety of assumptions to be made concerning the conditional distribution of postdropout outcomes that can be tailored to the estimand of interest. These assumptions can depend, for example, on the stated reasons for dropout. We illustrate these methods using data from 4 clinical trials of pregabalin for the treatment of painful diabetic peripheral neuropathy and postherpetic neuralgia. When planning chronic pain clinical trials, careful consideration of the trial objectives should determine the definition of the trial estimand, which in turn should inform methods used to accommodate missing data in the statistical analysis.

Background and Objectives Previous studies have shown that staff perception of team effectiveness is related to better health outcomes in various care settings. This study focused on the Veterans Health Administration’s Home-Based Primary Care (HBPC) program. We examined variations in HBPC interdisciplinary teamwork (IDT) and identified modifiable team and program characteristics that may influence staff perceptions of team effectiveness. Research Design We used a broadly validated survey instrument to measure perceived team effectiveness, workplace conditions/resources, group culture, and respondents’ characteristics. Surveys were initiated in January and completed in July, 2016. Methods Team membership rosters (n = 249) included 2,852 IDT members. The final analytical data set included 1,403 surveys (49%) from 221 (89%) teams. A generalized estimating equation model with logit link function, weighted by survey response rates, was used to examine factors associated with perceived team effectiveness. Results Respondents who served as primary care providers (PCPs) were 8% more likely (p = .0044) to view team’s performance as highly effective compared to other team members. Teams with nurse practitioners serving as team leader reported 6% higher likelihood of high-perceived team effectiveness (p = .0234). High team effectiveness was 13% more likely in sites where the predominant culture was characterized as group/developmental, and 7%–8% more likely in sites with lower environmental stress and better resources and staffing, respectively. Conclusions and Implications Team effectiveness is an important indirect measure of HBPC teams’ function. HBPC teams should examine their predominant culture, workplace stress, resources and staffing, and PCP leadership model as part of their quality improvement efforts.

Medicare beneficiaries with Alzheimer disease and related dementias (ADRD) are a particularly vulnerable group in whom arthritis is a frequently occurring comorbidity. Medicare's mandatory bundled payment reform-the Comprehensive Care for Joint Replacement (CJR) model-was intended to improve quality and reduce spending in beneficiaries undergoing joint replacement surgical procedures for arthritis. In the absence of adjustment for clinical risk, hospitals may avoid performing elective joint replacements for beneficiaries with ADRD.To evaluate the association of the CJR model with utilization of joint replacements for Medicare beneficiaries with ADRD.This cohort study used national Medicare data from 2013 to 2017 and multivariable linear probability models and a triple differences estimation approach. Medicare beneficiaries with a diagnosis of arthritis were identified from 67 metropolitan statistical areas (MSAs) mandated to participate in CJR and 104 control MSAs. Data were analyzed from July 2020 to July 2021.Implementation of the CJR model in 2016.Outcomes were separate binary indicators for whether or not a beneficiary underwent hip or knee replacement. Key independent variables were the MSA group, before-CJR and after-CJR phase, ADRD diagnosis, and their interactions. The linear probability models controlled for beneficiary characteristics, MSA fixed effects, and time trends.The study included 24 598 729 beneficiary-year observations for 9 624 461 unique beneficiaries, of which 250 168 beneficiaries underwent hip and 474 751 underwent knee replacements. The mean (SD) age of the 2013 cohort was 77.1 (7.9) years, 3 110 922 (66.4%) were women, 3 928 432 (83.8%) were non-Hispanic White, 792 707 (16.9%) were dually eligible for Medicaid, and 885 432 (18.9%) had an ADRD diagnosis. Before CJR implementation, joint replacement rates were lower among beneficiaries with ADRD (hip replacements: 0.38% vs 1.17% for beneficiaries with and without ADRD, respectively;In this cohort study of Medicare beneficiaries with arthritis, the CJR model was not associated with a decline in joint replacement utilization among beneficiaries with ADRD compared with beneficiaries without ADRD in the first 2 years of the program, thereby alleviating patient selection concerns.

BACKGROUND Confirmation of effectiveness of asthma biologics in the real world is desirable because patient characteristics and experiences may differ from those included in randomized controlled trials. OBJECTIVE To evaluate real-world effectiveness of asthma biologics and identify predictors of response. METHODS We performed a retrospective study in patients with severe asthma receiving biologics. The primary outcome was change in clinically significant exacerbations at 12 months after starting biologic therapy, compared with 12 months before. Secondary outcomes were change in severe exacerbations, maintenance oral corticosteroid (OCS) dose, prebronchodilator forced expiratory volume in 1 second (FEV1), and asthma control test scores. Subgroup analyses were performed for subjects who were biologic naive or not. A stepwise logistic regression model was performed to compare responders to nonresponders. RESULTS A total of 112 patients were included. Biologic therapy was associated with a 59% reduction in clinically significant exacerbations (P < .001), 65% reduction in severe exacerbations (P < .001), and 54% reduction in maintenance OCS dose (P = .001) in the 12 months after starting therapy. Biologics also resulted in improvement in prebronchodilator FEV1 (P = .002) and Asthma Control Test score (P < .001). Subjects who were previously on another biologic also experienced significant improvements in exacerbation frequency, maintenance OCS dose, and asthma control. Responders were more likely to be nonsmokers and have higher baseline FEV1, gastroesophageal reflux disease, and eosinophil counts greater than 500 cells/μL. CONCLUSION In a real-world setting, biologic therapy in asthma is effective in improving exacerbations, asthma control, and lung function. Patients who have a suboptimal response to 1 biologic can still benefit from treatment with a different biologic.

This secondary analysis used a 10% random sample from the national Outcome and Assessment Information Set (OASIS) of Medicare beneficiaries ≥ 65 years old who received home health (HH) care in 2017 (N=646,109). We examined the risk of hospital admission during a 60-day HH episode among Medicare home health patients in different living arrangements, including living alone at home (23.8%), living with other at home (64.8%), and residing in assisted facility (AL) facilities (11.4%). At the start of the HH episode, AL residents were older, more likely to have cognitive impairment, depressive symptoms, and limitations in activities of daily living (ADL) than those living at home at home (alone/with others). In the multivariable logistic regression model of hospital admission adjusting for demographic status (age, sex, race/ethnicity, Medicaid status), cognitive impairment, depressive symptoms, and ADL limitations, when compared to HH patients living with others at home (reference), AL residents were 15% less likely to have hospital admission (Odds Ratio [OR]=0.85, 95% Confidence Interval [CI]: 0.84, 0.88, p

Objective: The objective of this study was to examine the effects of dementia and Medicare–Medicaid dual eligibility on unplanned facility admission among older Medicare home health (HH) recipients. Method: This study involves a secondary analysis of data from the Outcome and Assessment Information Set (OASIS) and billing records (i.e., International Classification of Diseases, 10th Revision [ICD-10] codes) of 6,153 adults ≥ 65 years receiving HH from a nonprofit HH agency in CY 2017. Results: Among dual eligible patients with dementia, 39.3% had an unplanned facility admission of any type, including the hospital, nursing home, or rehabilitation facility. In the multivariable Cox proportional hazard model of time-to-facility admission, dual eligible patients with dementia were more than twice as likely as Medicare-only patients without dementia to have an unplanned facility admission (hazard ratio = 2.35; 95% confidence interval: 1.28, 4.33; p = .006). Discussion: Low income and dementia have interactive effects on facility admissions. Among Medicare HH recipients, dual eligible patients with dementia are the most vulnerable group for unplanned facility admission.