Medical Care最新文献

Background: Global shortages for 3 angiotensin receptor-II blockers (ARBs)-valsartan, losartan, and irbesartan-occurred in 2018-2019 after recalls due to ingredient impurities. Provider-level responses to the ARB shortages in the United States and spillovers to other antihypertensive classes are unknown.

Objective: To estimate changes in provider-level prescribing for ARBs and non-ARB antihypertensives up to 18 months after the 2018-2019 recalls and shortages.

Research design: National cohort study of prescribers using all-payer pharmacy claims. Mixed interrupted time series models quantified changes in prescribing postshortages and heterogeneous changes by specialty, region, medical school graduation cohort, sex, and level of prerecall prescribing.

Patients and methods: Active providers exposed to the 2018-2019 valsartan, irbesartan, and losartan shortages (defined as top-25th percentile for these drugs in 2017).

Measures: Within-class changes in prescribing for ARBs (recalled and nonrecalled). Between-class substitutions to non-ARB antihypertensives (ACE-Is, alpha- and beta-adrenergic blockers, calcium channel blockers, diuretics, and other agents).

Results: Among 138,032 prescribers who met the inclusion criteria, per-prescriber fills for valsartan decreased by 57%-59% after it was recalled in July 2018. We observed concurrent increases for losartan and irbesartan fills and no change in overall ARB prescribing. There were no significant changes in fills for ACE-Is or for other antihypertensives. Absolute decreases in valsartan fills were greatest among providers with higher levels of prescribing at baseline. However, relative changes did not differ by prescriber characteristics.

Conclusions: In this prescriber level, national study, substitutions to other ARBs mitigated decreases in valsartan fills after it was recalled. There were no spillovers to non-ARB anti-hypertensives. The availability of close substitutes during drug shortages may mitigate gaps in access for prescribers and their patients.

Background: Identification of transgender and gender diverse (TGD) people has been limited to diagnoses and text rather than self-identified gender identity (SIGI), representing a subset of TGD people. In 2017, the Veterans Health Administration (VHA) implemented SIGI, allowing for precise identification of TGD veterans, including subgroups (transgender man, transgender woman, and nonbinary).

Objectives: Health conditions, adverse social determinants of health (SDOH), and health care utilization were compared among veterans (1) identified by SIGI only, both SIGI and diagnosis/text, diagnosis/text only (ie, without SIGI), and (2) SIGI subgroups.

Research design: Cross-sectional.

Subjects: Twenty thousand seventy-nine TGD VHA patients from 2019 to 2023; SIGI only (n=5523), both SIGI and diagnosis/text (n=4066), and without SIGI (n=10,490).

Measures: Health conditions, adverse SODH and health care utilization.

Results: In adjusted models, SIGI only veterans were less likely to have documentation of depression (32.4% vs. 60.7% vs. 54.8%), post-traumatic stress disorder (PTSD; 23.5% vs. 41.4% vs. 37.5%), housing instability (8.8% vs. 21.5% vs. 16.1%), unemployment/financial problems (10.5% vs. 23.8% vs. 19.0%), and mental health visits (72.5% vs. 97.7% vs. 95.2%) compared with those with both SIGI and diagnosis/text and without SIGI. Health conditions were more similar across the diagnosis groups (i.e. both SIGI and diagnosis/text and without SIGI). Among veterans with SIGI data, we identified 49% transgender women, 38% transgender men, and 14% nonbinary veterans without many differences across subgroups. In adjusted models, more nonbinary veterans than transgender women and transgender men had documentation of alcohol use disorder (10.1% vs. 6.1% vs. 7.5%), depression (62.3% vs. 42.6% vs. 47.0%), PTSD (45.9% vs. 27.4% vs. 33.5%), mental health visits (96.7% vs. 89.1% vs. 91.9%), and experienced unemployment/financial problems (21.3% vs. 16.9% vs. 14.7%).

Conclusions: Without diagnosis, SIGI enables the identification of healthier TGD veterans. Regardless of SIGI, diagnosis signals much higher rates of health concerns. SIGI data facilitates understanding veteran subgroups, informing TGD policy and practice.

Background: Older adults with Alzheimer's disease and related dementias can benefit from palliative care (PC). Whether specialty and nonspecialty PC have the same effect on outcomes is unclear. We examined the effects of these 2 interventions on comfort, symptom management, satisfaction with care, and potentially burdensome transitions, including hospital admission, emergency department visit, intensive care unit admission in the end-of-life, and in-hospital death.

Methods: This PRISMA-adherent systematic review involved a search of PubMed, Medline, EMBASE, Cochrane Library, ProQuest, and CINAHL for studies published from January 1, 2013, to November 4, 2024. Primary studies that reported at least one of the 7 patient-level outcomes were included: Comfort Assessment in Dying with Dementia (CAD-EOLD), Symptom Management at the End-of-Life (SM-EOLD), Satisfaction with Care at the End-of-Life in Dementia (SWC-EOLD), hospital admissions, emergency department visits, intensive care unit admissions, and in-hospital death.

Results: Nineteen articles involving 142,772 participants were included. The evidence, comprising studies of adequate to strong quality, revealed that both specialty and nonspecialty PC did not differ in terms of comfort, symptom management, or satisfaction with care. However, both approaches significantly reduced the likelihood of intensive care unit admissions and in-hospital deaths. Specialty PC was associated with decreased emergency department visits (OR 0.53, 95% CI 0.28-1.00; I2=86%).

Conclusions: Future research is needed to understand factors influencing PC interventions that can improve comfort, symptom management, and care satisfaction for these individuals and their families.

Background: Timely access to regular dental visits allows the detection of preventable conditions at an earlier stage. Nonetheless, 37% of adults aged 18 and above had no dental visits in 2020. Various factors affect utilization, but little is known about the influence of job characteristics. This study examined the association between paid sick leave (PSL) and different types of dental services utilization among working adults aged 18-64 in the United States.

Methods: The study sample population included employed adults aged 18-64 in the 2019 Medical Expenditure Panel Survey (N=7645). The four outcome variables were a binary variable of having any dental care, including preventive, diagnostic, and treatment dental care in the past 12 months. The primary independent variable was having PSL as a job benefit. A multivariable logistic model was used, adjusting for demographics, socioeconomic status, and general health status. All analyses were adjusted for complex survey design.

Results: Seventy-three percent of working adults had paid sick leave benefits. Availability of PSL was significantly associated with higher utilization of any dental visits [Adjusted odds ratio (aOR): 1.38, 95% CI: 1.17-1.63], preventive dental care (aOR: 1.33, 95% CI: 1.12-1.57), and diagnostic dental care (aOR: 1.31, 95% CI: 1.11-1.55).

Conclusions: PSL is associated with a significant increase in dental services, preventive dental, and diagnostic dental visits. The study offers insights for medical practitioners and policymakers aiming to prevent adverse oral health outcomes, reduce disparities, and manage health care costs.

Background: Coordination of care between providers may help ensure that cancer survivors receive the appropriate health care services to improve their long-term health. We examined associations between a claims-based measure of care coordination and several health outcomes among older endometrial cancer survivors.

Methods: Using SEER-Medicare data, we identified women with endometrial cancer at ages 66+ during 2009-2015 (N=13,696). Medicare claims during years 1-3 postdiagnosis were used to calculate care density, a measure of care coordination, as the ratio of the number of patients shared among a woman's outpatient providers to the number of provider pairs seen by that patient. We estimated associations between care density tertile and hospitalizations, emergency room (ER) visits, and all-cause mortality from 3 years postdiagnosis on, and adherence to guideline-recommended follow-up during years 3-5 postdiagnosis.

Results: No clear trends were observed for risk of all-cause mortality, hospitalizations or ER visits according to care density category. However, for hospitalizations (HR=0.93; 95% CI: 0.87-0.99) and ER visits (HR=0.93; 95% CI: 0.88-0.98), there was a slightly lower risk in the highest care density tertile compared with the lowest. Women in the middle (OR=1.67; 95% CI: 1.40-2.00) and highest care density tertiles (OR=1.63; 95% CI: 1.36-1.96) were more likely to be adherent to follow-up recommendations than those in the lowest tertile.

Conclusions: Greater care coordination during the early survivorship period may be associated with a slightly lower risk of hospitalization and ER visits and better adherence to surveillance recommendations after endometrial cancer.

Objective: Magnet hospitals exhibit higher patient satisfaction than non-Magnet hospitals, yet the underlying mechanisms driving these differences remain underexplored. This study examined the associations between Magnet status, hospitals' inclusion efforts for diverse populations, and patient satisfaction, and whether inclusion efforts explain Magnet hospitals' higher satisfaction.

Methods: This cross-sectional study analyzed 2023 secondary data from 4 sources: the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS), the Healthcare Equality Index (HEI), the American Hospital Association Annual Survey, and the list of Magnet-recognized organizations. The sample included 708 hospitals (216 Magnet, 492 non-Magnet) participating in both HCAHPS and HEI. HEI scores, which assess hospitals' inclusion efforts for lesbian, gay, bisexual, transgender, queer, and other sexual and gender diverse (LGBTQ+) populations, were used as a proxy for overall inclusion. Patient satisfaction was measured using 8 HCAHPS indicators. Mediation analyses tested whether HEI scores explained the association between Magnet designation and patient satisfaction.

Results: Magnet hospitals had higher HEI scores (M=92.0, SD=12.2) compared with non-Magnet hospitals (M=88.5, SD=13.3). They also had higher hospital ratings (M=88.4, SD=2.4 vs. M=87.6, SD=3.3) and patient recommendations (M=88.4, SD=3.2 vs. M=86.8, SD=4.1). Magnet status had direct effects on hospital ratings (b=1.75, P <0.001) and recommendations (b=2.37, P <0.001), as well as indirect effects through HEI performance on hospital ratings (b=0.07, P =0.022) and recommendations (b=0.10, P =0.026), resulting in total effects on hospital ratings (b=1.82, P <0.001) and recommendations (b=2.47, P <0.001).

Conclusions: The findings underscore the importance of organizational priorities and policies that promote patient-centeredness and inclusion for the satisfaction of all patients.

Background and objectives: To improve upon existing hospital grading systems, we developed a new report card based on multivariate matching.

Research design: Matched cohorts. For each focal hospital patient, we match 10 control patients treated at "well-resourced" hospitals with excellent hospital characteristics from across the nation, and 10 control patients treated at "typical" hospitals, on over 300 patient characteristics from Medicare Claims. Grades were based on outcome differences between patients at the focal hospital and their matched controls. We also create an "Analogous" match that is comprised of multiple control patients matched to each focal hospital patient with similar patient characteristics who were treated at hospitals with similar characteristics to the focal hospital, answering the question, "How would patients who looked like my patients and who were treated at hospitals like my hospital fare, compared to how my patients fared." We also report outcomes by multimorbidity status.

Subjects: Medicare admissions from 2017 to 2019 for heart attack, heart failure and pneumonia. To illustrate our methods, we report on 4 hospitals in the same region: a well-known "Flagship" teaching Hospital, an Affiliated Hospital within the same flagship system, a Poor-Performing Hospital that is not part of the flagship system, and a Small Hospital with unstable estimates.

Measures: Thirty-day mortality and revisit rates.

Results: Report cards for each example hospital.

Conclusions: Matched report cards allow users to better benchmark hospitals and see those types of patients where a specific hospital is performing poorly compared to other hospitals treating very similar patients.

Background: In 2021, the Veterans Health Administration (VA) initiated a Tele-Emergency Care (TEC) program, where care is provided through phone or video by an emergency medicine provider to Veterans with urgent, unscheduled medical concerns. Early data suggest TEC effectively resolves Veterans' care concerns and decreases low-value emergency department visits. Equity of TEC receipt has yet to be assessed.

Objective: To assess differences, by race and ethnicity, of Veterans' receipt of TEC.

Research design: Cross-sectional study.

Subjects: Veterans who used TEC and/or low-acuity in-person VA emergency care in Southern California, Arizona, and New Mexico, from March 1, 2021 to May 1, 2023.

Measures: TEC and/or low-acuity in-person VA care use.

Results: Veterans who only had TEC visits were less likely than those who only had in-person visits to be of racial and ethnic minority groups, namely Asian (1.38% vs. 3.54%, P <0.001), Black (12.2% vs. 18.1%, P <0.001), and Hispanic (15.7 vs. 19.1%, P <0.001). These findings persisted once adjusting for covariates; having only TEC visits was less likely than only having in-person care for Veterans who were Asian [relative risk (RR): 0.47, P <0.001], Black (RR: 0.61, P <0.001) or Hispanic (RR: 0.87, P <0.001), compared with White Veterans.

Conclusions: Receipt of TEC, or both TEC and in-person care, rather than exclusively in-person care, is lower among Asian, Black, and Hispanic Veterans compared with White Veterans, independent of covariates. To promote equity, future work should determine and address root causes of disparities, including digital device access, triage processes, and Veteran experiences.