Healthcare Disparities Among Homeless Patients Hospitalized With Gastrointestinal Bleeding: A Propensity-Matched, State-Level Analysis.

GOALS: Examine outcomes among homeless patients admitted with gastrointestinal (GI) bleeding, including all-cause mortality and endoscopic intervention rates. BACKGROUND: Hospitalizations among homeless individuals have increased steadily since at least 2007 but little is known about GI outcomes in these patients. STUDY: The 2010-2014 Healthcare Utilization Project (HCUP) State Inpatient Databases from New York and Florida were used to identify adults admitted with a primary diagnosis of acute upper or lower GI bleed. Homeless patients were 1:3 matched with nonhomeless patients using a propensity-score greedy-matched algorithm. The primary outcome (all-cause in-hospital mortality) and secondary outcomes (30-day readmission rates, endoscopy utilization, length of stay, and total hospitalization costs) were compared. RESULTS: We matched 4074 homeless patients with 12,222 nonhomeless patients. Most hospitalizations for homeless individuals were concentrated in 113 (26.4%) of 428 hospitals. Homeless adults were more likely to be younger, male, African American or Hispanic, and on Medicaid. They experienced significantly higher odds of all-cause inpatient mortality compared with nonhomeless patients admitted with GI bleeding (OR 1.37, 95% CI 1.11-1.69). Endoscopy utilization rates were also lower for both upper (OR 0.62, 95% CI 0.55-0.71) and lower (OR 0.76, 95% CI 0.68-0.85) GI bleeding, though upper endoscopy rates within the first 24 hours were comparable (OR 1.11, 95% CI 1.00-1.23). Total hospitalization costs were lower ($9,715 vs. $12,173, P <0.001) while 30-day all-cause readmission rates were significantly higher in the homeless group (14.9% vs. 18.4%, P <0.001). CONCLUSIONS: Homeless patients hospitalized for GI bleeding face disparities, including higher mortality rates and lower endoscopy utilization.

The fragility of randomized placebo-controlled trials for irritable bowel syndrome.

BACKGROUND: The fragility index (FI) represents the number of participants whose status in a trial would have to change from a non-event (not experiencing the primary endpoint) to an event (experiencing the primary endpoint) in order to turn a statistically significant result into a non-significant result. We sought to evaluate the fragility indices of irritable bowel syndrome [IBS-mixed (IBS-M), IBS-constipation (IBS-C), & IBS-diarrhea (IBS-D)] trials. METHODS: Irritable bowel syndrome trials published in high-impact journals were identified from Medline. Trials had to be in adults, randomized, parallel-armed, with at least one statistically significant binary outcome, and an achieved primary endpoint of therapeutic efficacy. FI and correlation coefficients were calculated, and regression modeling used to identify predictors of a high FI. KEY RESULTS: Twelve trials were analyzed with a median FI of 6 (range: 0-38). Median sample size in all trials was 366 (range: 44-856). Trial publication year (p = 0.71), journal impact factor (p = 0.52), duration of study (p = 0.12), and number need to treat [NNT] (p = 0.29) were not predictive of a high FI. While a lower p-value correlated with a higher FI (p = 0.039), no correlation was noted between FI and impact factor (R = -0.20, p = 0.52), trial publication year (R = 0.12, p = 0.71), duration of trial (R = -0.46, p = 0.13), NNT (R = -0.34, p = 0.29), and sample size (R = 0.23, p = 0.5). The highest FI was in a Ramosetron trial (FI = 30) for IBS-D. CONCLUSION & INFERENCES: A median of six participants is needed to nullify results in the included IBS trials suggesting how easily statistical significance based on a threshold p-value may be overturned.

The Effects of Chronic Disease on Ambulatory Care-Sensitive Hospitalizations for Children or Youth.

Considerable research has focused on hospitalizations for ambulatory care-sensitive conditions (ACSHs), but little of that research has focused on the role played by chronic disease in ACSHs involving children or youth (C/Y). This research investigates, for C/Y, the effects of chronic disease on the likelihood of an ACSH. The database included 699 473 hospital discharges for individuals under 18 in Texas between 2011 and 2015. Effects of chronic disease, individual, and contextual factors on the likelihood of a discharge involving an ACSH were estimated using logistic regression. Contrary to the results for adults, the presence of chronic diseases or a complex chronic disease among children or youth was protective, reducing the likelihood of an ACSH for a nonchronic condition. Results indicate that heightened ambulatory care received by C/Y with chronic diseases is largely protective. Two of more chronic conditions or at least one complex chronic condition significantly reduced the likelihood of an ACSH.

Same- vs Different-Hospital Readmissions in Patients With Cirrhosis After Hospital Discharge.

INTRODUCTION: There is a lack of data on the impact of readmission to the same vs a different hospital following an index hospital discharge in cirrhosis patients. METHODS: We sought to describe rates and predictors of different-hospital readmissions (DHRs) among patients with cirrhosis and also determine the impact on cirrhosis outcomes including all-cause inpatient mortality and hospital costs. Using the national readmissions database, we identified cirrhosis hospitalizations in 2013. Regression analysis was used to determine the predictors of DHRs. A time-to-event analysis was performed to assess the impact on subsequent readmissions and all-cause inpatient mortality. RESULTS: In 2013, there were 109,039 cirrhosis readmissions with 67% of these being same-hospital readmissions and 33% being DHRs (P < 0.001). Two percent of readmitted patients were treated at ≥4 different hospitals. The 30-day readmission rate was 29.1%. Predictors of DHR included Medicaid payer (adjusted odds ratio [OR] 1.07, 95% confidence interval [95% CI] 1.01-1.14), age (OR 0.98, 95% CI 0.978-0.982), elective admission (OR 1.09, 95% CI 1.01-1.17), hepatic encephalopathy (OR 1.20, 95% CI 1.16-1.25), hepatorenal syndrome (OR 1.09, 95% CI 1.03-1.16), and low socioeconomic status (OR 1.15, 95% CI 1.06-1.25). No difference was observed in 30-day readmission risk following a DHR (adjusted hazard ratio 1.044, 95% CI 0.975-1.118). In addition, there was no increased risk of inpatient death observed during a DHR within 30 days (adjusted hazard ratio 1.08, 95% CI 0.94-1.23). However, patients with DHR had significantly higher hospital costs and length of stay. CONCLUSIONS: Majority of cirrhosis readmissions are same-hospital readmissions. Different-hospital readmissions do not increase the risk of 30-day readmissions and inpatient mortality but are associated with higher hospital costs.

Post-acute care for children with special health care needs.

BACKGROUND: Almost all studies of post-acute care (PAC) focus on older persons, frequently those suffering from chronic health problems. Some research is available on PAC for the pediatric population in general. However, very few studies focus on PAC services for children with special health care needs (SHCN). OBJECTIVE: To investigate factors affecting the provision of PAC to children with SHCN. METHODS: Pooled cross-sectional data from Texas Department of State Health Services hospital discharge database from 2011-2014 were analyzed. Publicly available algorithms identified chronic conditions, complex chronic conditions, and the principal problem leading to hospitalization. Analysis involved estimating two logistic regressions, with clustered robust standard errors, concerning the likelihood of receiving PAC and where that PAC was delivered. Models included patient characteristics and conditions, as well as hospital characteristics and location. RESULTS: Only 5.8 percent of discharges for children with SHCN resulted in the provision of PAC. Two-thirds of PAC was provided in a health care facility (HCF). Severity of illness and the number of complex chronic conditions, though not the number of chronic problems, made PAC more likely. Patient demographics had no effect on PAC decisions. Hospital type and location also affected PAC decision-making. CONCLUSIONS: PAC was provided to relatively few children with SHCN, which raises questions concerning the potential underutilization of PAC for children with SHCN. Also, the provision of most PAC in a HCF (66%) seems at odds with professional judgment and family preferences indicating that health care for children with SHCN is best provided in the home.

Multilevel Comparisons of Hospital Discharge among Older Adults with a Fall-Related Hospitalization.

OBJECTIVE: We examined multilevel factors associated with hospital discharge status among older adults suffering a fall-related hospitalization. DATA SOURCES: The 2011-2013 (n = 131,978) Texas Inpatient Hospital Discharge Public-Use File was used. STUDY DESIGN/METHODS: Multilevel logistic regression analyses estimated the likelihood of being discharged to institutional settings versus home. PRINCIPAL FINDINGS: Factors associated with a greater likelihood of being discharged to institutional settings versus home/self-care included being female, white, older, having greater risk of mortality, receiving care in a non-teaching hospital, having Medicare (versus Private) coverage, and being admitted from a non-health care facility (versus clinical referral). CONCLUSIONS: Understanding risk factors for costly discharges to institutional settings enables targeted fall-prevention interventions with identification of at-risk groups and allows for identifying policy-related factors associated with discharge status.

Factors associated with antibiotic prescriptions for the viral origin diseases in office-based practices, 2006-2012.

OBJECTIVE: To test the potential association between time spent with a doctor and antibiotic overprescriptions in case of the common cold, runny nose, bronchitis, chest colds, flu, sore throats, and fluid in the middle ear. DESIGN: Cross-sectional study. SETTING: Office-based physicians in the US. PARTICIPANTS: A total of 261,623 patient visits recorded to office-based physicians in the US. MAIN OUTCOME MEASURES: The interest outcome was unnecessary antibiotic prescription. RESULTS: The analysis revealed five significant predictors of antibiotic prescriptions for suspected viral infections: length of doctor-patient encounter time, patient gender, spending time with a family medicine doctor, type of insurance, and the rate of antibiotic prescriptions per physician. For every additional minute a patient spent with a physician during a visit, the mean predicted probability of receiving unnecessary antibiotics decreased by 2.4%. CONCLUSIONS: This study provided evidence that physicians continue to prescribe antibiotics in avoidable cases. Policies that would monitor antibiotic prescription in office-based settings should be considered in order to control spreading of antibiotic resistance and eventually improve population health.

Post-acute Care for Children and Youth in Texas, 2011-2014.

Little is known about services provided to children and youth (C/Y) discharged from an acute care facility. Recent research has provided a foundation for efforts to supplement or complement that early work. This research investigates post-acute care (PAC) in Texas. It focuses on what differentiates those discharges that receive PAC from those that do not and on what differentiates those C/Y who receive PAC in a health care facility from those who receive home health services. The results show that only 6.4% of discharges involving C/Y receive PAC and that many factors affected the 2 issues under investigation quite differently. These results clearly demonstrate the low prevalence of PAC use for C/Y and the clear preference of using PAC home health in this population.

Impact of a decision-making aid for suspected urinary tract infections on antibiotic overuse in nursing homes.

BACKGROUND: Antibiotics are highly utilized in nursing homes. The aim of the study was to test the effectiveness of a decision-making aid for urinary tract infection management on reducing antibiotic prescriptions for suspected bacteriuria in the urine without symptoms, known as asymptomatic bacteriuria (ASB) in twelve nursing homes in Texas. METHOD: A pre- and post-test with comparison group design was used. The data was collected through retrospective chart review. The study sample included 669 antibiotic prescriptions for suspected urinary tract infections ordered for 547 nursing home residents. The main measurement for the outcome variable was whether an antibiotic was prescribed for suspected urinary tract infections with no symptoms present. RESULTS: Most of the prescriptions for antibiotics UTIs were written without documented symptoms - thus for asymptomatic bacteuria (ASB) (71 % during the pre-intervention period). Exposure to the decision-making aid decreased the number of prescriptions written for ASB (from 78 % to 65 % in the low-intensity homes and from 65 % to 57 % in the high-intensity homes), and decreased odds of a prescription being written for ASB (OR = 0.63, 95 % CI = 0.25 - 1.60 for low-intensity homes; OR = 0.79, 95 % CI = 0.33 - 1.88 for high-intensity homes). The odds of a prescription being written for ASB decreased significantly in homes that succeeded in implementing the decision-making aid (OR = 0.35, 95 % CI = 0.16-0.76), compared to homes with no fidelity. CONCLUSIONS: The decision-making aid improved antibiotic stewardship in nursing homes.

When concealed handgun licensees break bad: criminal convictions of concealed handgun licensees in Texas, 2001-2009.

OBJECTIVES: We explored differences in criminal convictions between holders and nonholders of a concealed handgun license (CHL) in Texas. METHODS: The Texas Department of Public Safety (DPS) provides annual data on criminal convictions of holders and nonholders of CHLs. We used 2001 to 2009 DPS data to investigate the differences in the distribution of convictions for these 2 groups across 9 types of criminal offenses. We calculated z scores for the differences in the types of crimes for which CHL holders and nonholders were convicted. RESULTS: CHL holders were much less likely than nonlicensees to be convicted of crimes. Most nonholder convictions involved higher-prevalence crimes (burglary, robbery, or simple assault). CHL holders' convictions were more likely to involve lower-prevalence crimes, such as sexual offenses, gun offenses, or offenses involving a death. CONCLUSIONS: Our results imply that expanding the settings in which concealed carry is permitted may increase the risk of specific types of crimes, some quite serious in those settings. These increased risks may be relatively small. Nonetheless, policymakers should consider these risks when contemplating reducing the scope of gun-free zones.

Asymptomatic bacteriuria, antibiotic use, and suspected urinary tract infections in four nursing homes.

BACKGROUND: Urinary tract infections (UTIs) are the most commonly treated infection among nursing home residents. Even in the absence of specific (e.g., dysuria) or non-specific (e.g., fever) signs or symptoms, residents frequently receive an antibiotic for a suspected infection. This research investigates factors associated with the use of antibiotics to treat asymptomatic bacteriuria (ASB) among nursing home residents. METHODS: This was a cross-sectional study involving multi-level multivariate analyses of antibiotic prescription data for residents in four nursing homes in central Texas. Participants included all nursing home residents in these homes who, over a six-month period, received an antibiotic for a suspected UTI. We investigated what factors affected the likelihood that a resident receiving an antibiotic for a suspected UTI was asymptomatic. RESULTS: The most powerful predictor of antibiotic treatment for ASB was the presence of an indwelling urinary catheter. Over 80 percent of antibiotic prescriptions written for catheterized individuals were written for individuals with ASB. For those without a catheter, record reviews identified 204 antibiotic prescriptions among 151 residents treated for a suspected UTI. Almost 50% of these prescriptions were for residents with no documented UTI symptoms. Almost three-quarters of these antibiotics were ordered after laboratory results were available to clinicians. Multivariate analyses indicated that resident characteristics did not affect the likelihood that an antibiotic was prescribed for ASB. The only statistically significant factor was the identity of the nursing home in which a resident resided. CONCLUSIONS: We confirm the findings of earlier research indicating frequent use of antibiotics for ASB in nursing homes, especially for residents with urinary catheters. In this sample of nursing home residents, half of the antibiotic prescriptions for a suspected UTI in residents without catheters occurred with no documented signs or symptoms of a UTI. Urine studies were performed in almost all suspected UTI cases in which an antibiotic was prescribed. Efforts to improve antibiotic stewardship in nursing homes must address clinical decision-making solely on the basis of diagnostic testing in the absence of signs or symptoms of a UTI.