Impact of anemia on outcomes and resource utilization in patients with myocardial infarction: A national database analysis.

BACKGROUND: Although anemia is common in patients with myocardial infarction (MI), management remains controversial. We quantified the association of anemia with in-hospital outcomes and resource utilization in patients admitted with MI using a large national database. METHODS: All hospitalizations with a primary diagnosis code for acute MI in the National Inpatient Sample (NIS) between 2014 and 2018 were identified. Among these hospitalizations, patients with anemia were identified using a secondary diagnosis code. Data on demographic and clinical variables were collected. Outcomes of interest included in-hospital adverse events, length of stay (LOS), and total cost. Multivariable logistic regression and generalized linear models were used to evaluate the relationship between anemia and outcomes. RESULTS: Among 1,113,181 MI hospitalizations, 254,816 (22.8%) included concomitant anemia. Anemic patients were older and more likely to be women. After adjustment for demographics and comorbidities, anemia was associated with higher mortality (7.1 vs. 4.3%; odds ratio 1.09; 95% confidence interval [CI] 1.07-1.12, p < 0.001). Anemia was also associated with a mean of 2.71 days longer LOS (average marginal effects [AME] 2.71; 95% CI 2.68-2.73, p < 0.05), and $ 9703 mean higher total costs (AME $9703, 95% CI $9577-$9829, p < 0.05). Anemic patients who received blood transfusions had higher mortality as compared with those who did not (8.2% vs. 7.0, p < 0.001). CONCLUSION: In MI patients, anemia was associated with higher in-hospital mortality, adverse events, total cost, and length of stay. Transfusion was associated with increased mortality, and its role in MI requires further research.

Impact of Community Socioeconomic Characteristics on Emergency Medical Service Delays in Responding to Fatal Vehicle Crashes.

Introduction: This study aimed to determine the impact of community socioeconomic status on emergency medical services' response time for fatal vehicle crashes. Methods: Authors used the 2019 National Highway Traffic Safety Administration Fatality Analysis Reporting System and 2019-2020 Area Health Resource Files to obtain emergency medical services' time intervals and county socioeconomic characteristics (e.g., median household income, availability of trauma centers, and rurality), generating a study sample of 18,540 individuals involved in fatal vehicle crashes between January and December 2019. Generalized linear models with log-link and Gamma-family were used to obtain estimates, and other variables were adjusted in the model. Results: Both the mean time of the emergency medical service arrival to the site of the crash and the mean transport time from the crash site to hospital varied by county SES. Counties with a higher mean household income had 12% shorter emergency medical services' arrival times and up to 7% shorter emergency medical services' hospital transport times than counties with lower SES. The emergency medical services' hospital transport times by emergency medical services also varied by proximity to trauma centers and were 15% shorter in counties that had ≥2 trauma centers than in counties without trauma centers. Conclusions: This study shows socioeconomic disparities in emergency medical service rescue time for fatal vehicle crashes. Community characteristics play a major role in emergency medical services' arrival time intervals. Prior research demonstrated a strong link between the timeliness of emergency medical service response and the likelihood of survival in fatal motor vehicle accidents. These findings showing that socioeconomically disadvantaged areas and those lacking trauma facilities had slower emergency medical service rescue times, suggest that socioeconomic status may be a predictor of mortality in fatal motor vehicle accidents. Effective emergency medical services are essential to reduce the morbidity and mortality among motor vehicle crash victims; however, disparities exist in the timeliness of these services by geographic and socioeconomic county characteristics. Further research is urgently needed to inform policy interventions.

Impact of functional disability on health-care use and medical costs among cancer survivors.

BACKGROUND: Cancer survivors with a disability are among the most vulnerable in health status and financial hardship, but no prior research has systematically examined how disability modifies health-care use and costs. This study examined the association between functional disability among cancer survivors and their health-care utilization and medical costs. METHODS: We generated nationally representative estimates using the 2015-2019 Medical Expenditure Panel Survey. Outcomes included use of 6 service types (inpatient, outpatient, office-based physician, office-based nonphysician, emergency department, and prescription) and medical costs of aggregate services and by each of 6 service types. The primary independent variable was a categorical variable for the total number of functional disabilities. We employed multivariable generalized linear models and 2-part models, adjusting for sociodemographics and health conditions and accounting for survey design. RESULTS: Among cancer survivors (n = 9359; weighted n = 21 046 285), 38.8% reported at least 1 disability. Compared with individuals without a disability, cancer survivors with 4 or more disabilities experienced longer hospital stays (adjusted average marginal effect = 1.14 days, 95% confidence interval [CI] = 0.55 to 1.73), more visits to an office-based physician (average marginal effect = 1.43 visits, 95% CI = 0.51 to 2.35), and a greater number of prescriptions (average marginal effect = 12.1 prescriptions, 95% CI = 9.27 to 15.0). Their total (average marginal effect = $9537, 95% CI = $5713 to $13 361) and out-of-pocket (average marginal effect = $639, 95% CI = $79 to $1199) medical costs for aggregate services were statistically significantly higher. By type, disability in independent living was most strongly associated with greater costs for aggregate services. CONCLUSIONS: Cancer survivors with a disability experienced greater health-care use and higher costs. Cancer survivorship planning for health care and financial stability should consider the patients' disability profile.

A National Perspective of Telemedicine Use and Direct Medical Costs: Who Uses It and How Much It Costs.

BACKGROUND: Telemedicine has the potential to reduce medical costs among health systems. However, there is a limited understanding of the use of telemedicine and its association with direct medical costs. OBJECTIVES: Using nationally representative data, we investigated telemedicine use and the associated direct medical costs among respondents overall and stratified by medical provider type and patient insurance status. RESEARCH DESIGN, SUBJECTS, AND MEASURES: We used the 2020 Medical Expenditure Panel Survey full-year consolidated file, and outpatient department (OP) and office-based (OB) medical provider event files. Outcomes included total and out-of-pocket costs per visit for OP and OB. The primary independent variable was a binary variable indicating visits made through any telemedicine modality. We used multivariable generalized linear models and 2-part models, adjusting for types of providers and care, patient characteristics, and survey design. RESULTS: Among total OP (n = 2938) and OB (n = 20,204) visits, 47.6% and 24.7% of visits, respectively were made through telemedicine. For OP, telemedicine visits were associated with lower total costs (average marginal effect: -$228; 95% confidence interval -$362, -$95) and out-of-pocket costs for all visits and for visits to specialists and to nurse practitioners or physicians assistants. For OB, telemedicine visits were associated with lower total costs, but not with lower out-of-pocket costs, for visits to primary care physicians or nurse practitioners or physician assistants, and for visits by Medicare patients. CONCLUSION: Telemedicine was associated with lower direct medical costs. Its potential for cost curbing should be proactively identified and integrated into clinical practice and health policy design.

Assessment of Uptake Appropriateness of Computed Tomography for Lung Cancer Screening According to Patients Meeting Eligibility Criteria of the US Preventive Services Task Force.

Importance: Currently, computed tomography (CT) is used for lung cancer screening (LCS) among populations with various levels of compliance to the eligibility criteria from the US Preventive Services Task Force (USPSTF) recommendations and may represent suboptimal allocation of health care resources. Objective: To evaluate the appropriateness of CT LCS according to the USPSTF eligibility criteria. Design, Setting, and Participants: This cross-sectional study used the 2019 Behavioral Risk Factor Surveillance System (BRFSS) survey. Participants included individuals who responded to the LCS module administered in 20 states and had valid answers to questions regarding screening and smoking history. Data were analyzed between October 2021 and August 2022. Exposures: Screening eligibility groups were categorized according to the USPSTF 2013 recommendations, and subgroups of individuals who underwent LCS were analyzed. Main Outcomes and Measures: Main outcomes included LCS among the screening-eligible population and the proportions of the screened populations according to compliance categories established from the USPSTF 2013 and 2021 recommendations. In addition, the association between respondents' characteristics and LCS was evaluated for the subgroup who were screened despite not meeting any of the 3 USPSTF screening criteria: age, pack-year, and years since quitting smoking. Results: A total of 96 097 respondents were identified for the full study cohort, and 2 subgroups were constructed: (1) 3374 respondents who reported having a CT or computerized axial tomography to check for lung cancer and (2) 33 809 respondents who did not meet any screening eligibility criteria. The proportion of participants who were under 50 years old was 53.1%; between 50 and 54, 9.1%; between 55 and 79, 33.8%; and over 80, 4.0%. A total of 51 536 (50.9%) of the participants were female. According to the USPSTF 2013 recommendation, 807 (12.8%) of the screening-eligible population underwent LCS. Among those who were screened, only 807 (20.9%) met all 3 screening eligibility criteria, whereas 538 (20.1%) failed to meet any criteria. Among respondents in subgroup 2, being of older age and having a history of stroke, chronic obstructive pulmonary disease, kidney disease, or diabetes were associated with higher likelihood of LCS. Conclusions and Relevance: In this cross-sectional study of the BRFSS 2019 survey, the low uptake rate among screening-eligible patients undermined the goal of LCS of early detection. Suboptimal screening patterns could increase health system costs and add financial stress, psychological burden, and physical harms to low-risk patients, while failing to provide high-quality preventive services to individuals at high risk of lung cancer.

Household disinfection practices by women living in Egypt during the 2020 COVID-19 lockdown and the association of information sources and suspected bleach toxicity.

INTRODUCTION: The spread of contradictory health information was a hallmark of the early COVID-19 pandemic. Because of a limited understanding of the disease, its mode of transmission, and its pathogenicity, the public turned to easily accessible and familiar sources of information. Some of these sources included wrong or incomplete information that could increase health risks and incidents of toxicity due to improper information about the usage of disinfectants. The objective of this study was to assess the relationship between sources of information about the COVID-19 pandemic, the related household cleaning and disinfection practices among adult women living in Egypt, and the associated adverse effects of bleach toxicity during a national lockdown. METHODS: Through a self-administered online survey, 452 adult women (18 years and older) living in Egypt were recruited from 13 cities between 4 June 2022 and 4 July 2022 to answer the questionnaire. The questionnaire included (41) questions in Arabic and collected data about respondents' household cleaning and disinfection practices to prevent the spread of the SARS-CoV-2 virus and protect their families during the lockdown that started in Egypt in March 2020. RESULTS: The study found that 88.1% (n = 398) of participants reported increased use of disinfectants during the lockdown. Women who chose social media as their primary source of information to learn about disinfection practices reported an increased frequency of respiratory symptoms associated with bleach toxicity (correlation coefficient = 0.10, p-value = 0.03), followed by women who depended on relatives and friends as the primary source of information (correlation coefficient = 0.10, p-value = 0.02). CONCLUSION: This study showed that social media is an easily accessible, efficient and fast communication tool that can act as a primary source for individuals seeking medical information compared to other media platforms (e.g., websites, T.V., satellite channels). However, better regulations and monitoring of its content may help limit the harms caused by the misinformation and disinformation spread by these popular platforms, particularly in times of uncertainty and upheaval.

The Impact of Meaningful Use and Electronic Health Records on Hospital Patient Safety.

The HITECH Act aimed to leverage Electronic Health Records (EHRs) to improve efficiency, quality, and patient safety. Patient safety and EHR use have been understudied, making it difficult to determine if EHRs improve patient safety. The objective of this study was to determine the impact of EHRs and attesting to Meaningful Use (MU) on Patient Safety Indicators (PSIs). A multivariate regression analysis was performed using a generalized linear model method to examine the impact of EHR use on PSIs. Fully implemented EHRs not attesting to MU had a positive impact on three PSIs, and hospitals that attested to MU had a positive impact on two. Attesting to MU or having a fully implemented EHR were not drivers of PSI-90 composite score, suggesting that hospitals may not see significant differences in patient safety with the use of EHR systems as hospitals move towards pay-for-performance models. Policy and practice may want to focus on defining metrics and PSIs that are highly preventable to avoid penalizing hospitals through reimbursement, and work toward adopting advanced analytics to better leverage EHR data. These findings will assist hospital leaders to find strategies to better leverage EHRs, rather than relying on achieving benchmarks of MU objectives.

Impact of race-specific screening guideline on the uptake of colorectal cancer screening among young African Americans.

BACKGROUND: African Americans (AAs) have had lower colorectal cancer (CRC) screening rates, higher incidence rate, and earlier mean age at onset. The 2017 U.S. Multi-Society Task Force (MSTF) recommended initiating CRC screening at age 45 for AAs and age 50 for non-AAs. OBJECTIVE: To investigate the impact of the 2017 MSTF's race-specific guidelines on CRC screening rate among young AAs. DESIGN, SETTING, AND PARTICIPANTS: We used the 2015 and 2018 National Health Interview Survey to provide nationally representative estimates. The study sample included adults aged between 45 and 75 without a history of CRC, excluding screening recipients for diagnosis or surveillance purposes. MAIN MEASURES: The outcome is a binary variable of CRC screening. Primary independent variables were age and race category (non-AAs aged 45-49, AAs 45-49, non-AAs 50-75, AAs 50-75), a binary variable indicating before or after the 2017 MSTF guideline (2015 vs. 2018), and their interaction terms. We employed a multivariable logistic model, adjusting for individual characteristics, and accounting for complex survey design. KEY RESULTS: Among the total sample (n = 21,735), CRC screening rate increased from 54.6% in 2015 to 58.5% in 2018 (p < 0.01). By age and race, the screening rate exhibited an increase for all age and race groups except for young non-AAs. Compared to young non-AAs, the adjusted predicted probability (APP) of screening for young AAs was significantly higher by 0.10 (average marginal effect, 0.10; 95% confidence interval, 0.01-0.19) in 2018, while the difference was insignificant in 2015. Racial differences in screening among older adults were not significant in both years. The CRC screening rate was substantially lower among young AAs compared to older AAs (17.2% vs. 65.5% in 2018). CONCLUSION: The race-specific recommendation is an effective policy tool to increase screening uptake and would contribute to reducing cancer disparities among racial/ethnic minorities.

Impact of Florida's prescription drug monitoring program on drug- related fatal vehicle crashes: a difference-in-differences approach.

BACKGROUND: Prescription drug use has soared in the USA within the last two decades. Prescription drugs can impair motor skills essential for the safe operation of a motor vehicle, and therefore can affect traffic safety. As one of the epicentres of the opioid epidemic, Florida has been struck by high opioid misuse and overdose rates, and has concurrently suffered major threats to traffic disruptions safety caused by driving under the influence of drugs. To prevent prescription opioid misuse in Florida, Prescription Drug Monitoring Programs (PDMPs) were implemented in September 2011. OBJECTIVE: To examine the impact of Florida's implementation of a mandatory PDMP on drug-related MVCs occurring on public roads. METHODS: We employed a difference-in-differences approach to estimate the difference in prescription drug-related fatal crashes in Florida associated with its 2011 PDMP implementation relative to those in Georgia, which did not use PDMPs during the same period (2009-2013). The analyses were conducted in 2020. RESULTS: In Florida, there was a significant decline in drug-related vehicle crashes during the 22 months post-PDMP. PDMP implementation was associated with approximately two (-2.21; 95% CI -4.04 to -0.37; p<0.05) fewer prescribed opioid-related fatal crashes every month, indicating 25% reduction in the number of monthly crashes. We conducted sensitivity analyses to investigate the impact of PDMP implementation on central nervous system depressants and stimulants as well as cocaine and marijuana-related fatal crashes but found no robust significant reductions. CONCLUSIONS: The implementation of PDMPs in Florida provided important benefits for traffic safety, reducing the rates of prescription opioid-related vehicle crashes.

The Impact of Electronic Health Records and Meaningful Use on Inpatient Quality.

ABSTRACT: It is unclear if national investments of the HITECH Act have resulted in significant improvements in care processes and outcomes by making "Meaningful Use (MU)" of Electronic Health Record (EHR) systems. The objective of this study is to determine the impact of EHRs and MU on inpatient quality. We used inpatient hospitalization data, American Hospital Association annual survey, and the Centers for Medicare and Medicaid Services attestation records to study the impact of EHRs on inpatient quality composite scores. Agency for Healthcare Research and Quality Inpatient Quality Indicator (IQI) software version 5.0 was used to compute the hospital-level risk-adjusted standardized rates for IQI indicators and composite scores. After adjusting for confounding factors, EHRs that attested to MU had a positive impact on IQI 90 and IQI 91 composite scores with an 8% decrease in composites for mortality for selected procedures and 18% decrease in composites for mortality for selected conditions. Meaningful Use attestation may be an important driver related to inpatient quality. Health care leaders may need to focus on quality improvement initiatives and advanced analytics to better leverage their EHRs to improve IQI 90 composite score for mortality for selected procedures, because we observed a lesser impact on IQI 90 compared with IQI 91.

Association of Intrinsic Motivating Factors and Joy in Practice: A National Physician Survey.

OBJECTIVES: In response to the need to identify positive measures that more accurately describe physician wellness, this study seeks to assess the validity of a novel joy in practice measure using validated physician well-being measures and test its association with certain intrinsic and extrinsic motivators. METHODS: Secondary data analysis using a nationally representative dataset of 2000 US physicians, fielded October-December 2011. Multivariable logistic models with survey design provided nationally representative individual-level estimates. Primary outcome variables included joy in practice (enthusiasm, fulfillment, and clinical stamina in an after-hours setting). Secondary outcomes were validated measures of physician well-being such as job and life satisfaction and life meaning. Primary explanatory variables were sense of calling, number of personally rewarding hours per day, long-term relationships with patients, and burnout. RESULTS: The survey response rate was 64.5% (1289/2000). Physicians who demonstrated joy in practice were most likely to report high life satisfaction (odds ratio [OR] 2.75, 95% confidence interval [CI] 1.52-4.98) and high life meaning (OR 2.62, 95% CI 1.41-4.85). Joy in practice was strongly associated with having a sense of calling (OR 10.8, 95% CI 2.21-52.8) and ≥ 7.5 personally rewarding hours per day (OR 3.75, 95% CI 1.51-9.36); meanwhile, it was negatively associated with burnout (OR 0.26, 95% CI 0.14-0.51). Extrinsic factors such as specialty, practice setting, and annual income were not significantly associated with joy in practice in most regressions. CONCLUSIONS: The joy in practice measure shows preliminary promise as a positive marker of well-being, highlighting the need for future interventions that support physicians' intrinsic motivators and foster joy in one's practice.

Association of Post-discharge Service Types and Timing with 30-Day Readmissions, Length of Stay, and Costs.

BACKGROUND: Although early follow-up after discharge from an index admission (IA) has been postulated to reduce 30-day readmission, some researchers have questioned its efficacy, which may depend upon the likelihood of readmission at a given time and the health conditions contributing to readmissions. OBJECTIVE: To investigate the relationship between post-discharge services utilization of different types and at different timepoints and unplanned 30-day readmission, length of stay (LOS), and inpatient costs. DESIGN, SETTING, AND PARTICIPANTS: The study sample included 583,199 all-cause IAs among 2014 Medicare fee-for-service beneficiaries that met IA inclusion criteria. MAIN MEASURES: The outcomes were probability of 30-day readmission, average readmission LOS per IA discharge, and average readmission inpatient cost per IA discharge. The primary independent variables were 7 post-discharge health services (institutional outpatient, primary care physician, specialist, non-physician provider, emergency department (ED), home health care, skilled nursing facility) utilized within 7 days, 14 days, and 30 days of IA discharge. To examine the association with post-discharge services utilization, we employed multivariable logistic regressions for 30-day readmissions and two-part models for LOS and inpatient costs. KEY RESULTS: Among all IA discharges, the probability of unplanned 30-day readmission was 0.1176, the average readmission LOS per discharge was 0.67 days, and the average inpatient cost per discharge was $5648. Institutional outpatient, home health care, and primary care physician visits at all timepoints were associated with decreased readmission and resource utilization. Conversely, 7-day and 14-day specialist visits were positively associated with all three outcomes, while 30-day visits were negatively associated. ED visits were strongly associated with increases in all three outcomes at all timepoints. CONCLUSION: Post-discharge services of different types and at different timepoints have varying impacts on 30-day readmission, LOS, and costs. These impacts should be considered when coordinating post-discharge follow-up, and their drivers should be further explored to reduce readmission throughout the health care system.

Mechanical Circulatory Support Following Out-of-Hospital Cardiac Arrest: Insights From the National Cardiogenic Shock Initiative.

BACKGROUND: Evidence is limited regarding the role of mechanical circulatory support (MCS) in patients with acute coronary syndromes (ACS) complicated by cardiogenic shock (CGS). In particular, the role of MCS in patients with out-of-hospital cardiac arrest (OHCA) is unknown. METHODS: The National Cardiogenic Shock Initiative (NCSI) is a multicenter United States registry of patients with ACS complicated by CGS treated with MCS. We compared the rate of survival to hospital discharge among patients with OHCA, in-hospital cardiac arrest (IHCA), or no cardiac arrest. We subsequently used multivariable analyses to determine independent predictors of OHCA survival. RESULTS: Survival to hospital discharge occurred in 85.7% (42/49) of OHCA, 72.4% (50/69) of IHCA, and 74.5% (111/149) of non-cardiac arrest patients. By multivariable analysis, pre-procedural predictors of survival included younger age, female sex, fewer diseased vessels, left anterior descending coronary artery culprit, lower troponin, higher lactate, and delayed initiation of MCS. Procedural and post-procedural predictors of survival included fewer vessels treated, complete revascularization, higher post-MCS cardiac power output, and fewer inotropic medications required. CONCLUSIONS: This study demonstrates that excellent outcomes may be achieved following OHCA when MCS is employed for patients appropriately selected by prognostic demographic, anatomic, and health status characteristics. A larger study population, currently being enrolled, is needed to validate the observation further.

Association of Preferences for Participation in Decision-making With Care Satisfaction Among Hospitalized Patients.

Importance: The association of patient desire to participate in health care decisions with care satisfaction is poorly understood. The contributions of such desire, expectations of care, and quality of care in assessing patient satisfaction are not known. Objective: To investigate the association of hospitalized patients' desire to delegate decisions to their physician with care dissatisfaction. Design, Setting, and Participants: Survey study in an academic research setting. As part of The University of Chicago Hospitalist Study, data were collected on 13 902 hospitalized patients admitted to the general internal medicine service of The University of Chicago Medical Center between July 1, 2004, and September 30, 2012, who answered an inpatient survey administered soon after the time of admission and a 30-day follow-up survey. The dates of analysis were January 2014 to June 2015. Exposure: Patient-reported preference to leave medical decisions to their physician (definitely agree or somewhat agree vs somewhat disagree or definitely disagree). Main Outcomes and Measures: The main outcomes were patient-reported dissatisfaction with overall service, dissatisfaction with physician care, and lack of confidence and trust in the physicians providing treatment, which were obtained from the 30-day follow-up survey. Results: The sample population included 13 902 patients (mean [SD] age, 56.7 [19.1] years; 60.4% female [n = 8397] and 74.2% African American [n = 10 310]) who completed both surveys. Overall, 53.2% had no higher educational attainment, 22.7% were insured by Medicaid, and 51.1% reported a general self-assessed health status of fair or poor. The proportions of respondents who agreed and disagreed with delegating decisions to the responsible physician were 71.1% and 28.9%, respectively. A statistically significantly higher proportion of those who agreed rated their overall care as excellent or very good compared with those who disagreed (68.0% vs 62.5%; P < .001). Similarly, a statistically significantly higher proportion of those who agreed were extremely satisfied with the physician care received (67.8% vs 62.5%; P < .001). In the multivariable logistic regression models, compared with those patients who definitely agreed with delegation, patients who definitely disagreed were more likely to be dissatisfied with overall service (odds ratio [OR], 1.86; 95% CI, 1.54-2.24) and the physician care received (OR, 1.78; 95% CI, 1.42-2.22) and lack confidence and trust in the physicians providing treatment (OR, 2.05; 95% CI, 1.62-2.59). Conclusions and Relevance: The findings suggest that patient preferences to participate in medical decision-making are statistically significantly associated with dissatisfaction of hospitalized patients. Clinicians should individualize their encouragement of patient participation in diagnostic and management decisions to maximize patient satisfaction.

Relative Costs of Surgical and Transcatheter Aortic Valve Replacement and Medical Therapy.

BACKGROUND: The number of patients treated for aortic valve disease in the United States is increasing rapidly. Transcatheter aortic valve replacement (TAVR) is supplanting surgical aortic valve replacement (SAVR) and medical therapy (MT). The economic implications of these trends are unknown. Therefore, we undertook to determine the costs, inpatient days, and number of admissions associated with treating aortic valve disease with SAVR, TAVR, or MT. METHODS: Using the Nationwide Readmissions Database, we identified patients with aortic valve disease admitted 2012 to 2016 for SAVR, TAVR, and disease symptoms (congestive heart failure, unstable angina, non-ST-elevation myocardial infarction, syncope). Patients not undergoing SAVR or TAVR were classified as receiving MT. Beginning with the index admission, we estimated inpatient costs, days, and admissions over 6 months. RESULTS: Among 190 563 patients with aortic valve disease, the average aggregate 6-month inpatient costs were $59 743 for SAVR, $64 395 for TAVR, and $23 460 for MT. Mean index admission was longer for SAVR (10.0 days) than for TAVR (7.0 day) or MT (5.3 days), but the average number of unplanned readmission inpatient days was 2.0 for SAVR, 3.0 for TAVR, and 4.3 for MT; the average number of total admissions was 1.3 for SAVR, 1.5 for TAVR, and 1.7 for MT (P<0.01 for all). TAVR index admission costs decreased over time to become similar to SAVR costs by 2016. CONCLUSIONS: Aggregate costs were higher for TAVR than SAVR and were significantly more expensive than MT alone. However, TAVR costs decreased over time while SAVR and MT costs remained unchanged.

Utilisation of emergency departments of behavioural disorders and supply of workforce in Nebraska.

BACKGROUND: Emergency departments (EDs) have become entry points for treating behavioural health (BH) conditions, thereby rendering the evaluation of their utilisation necessary. OBJECTIVES: This study estimated behavioural-related hospital-based ED visits and outcomes of leaving against medical advice as well as the incurred charges within the primarily rural State of Nebraska. Also, the study correlated behavioural workforce distribution and location of EDs with ED utilisation. METHODS: Nebraska State Emergency Department Database provided information on utilisation of services, charges, diagnoses and demographic. Health Professional Tracking Services survey provided the distribution of EDs and BH workforce by region. To examine the effect of patient characteristics on discharge against medical advice, multivariable logistic regression modelling was used. FINDINGS: US$96.4 million were ED charges for 52 035 visits for BH disorders over 3 years. Of these, 35% and 50% were between 25 and 44-years old and privately insured, respectively. The uninsured (OR:1.53, p=0.0047) and 45-64 years old (OR:2.31, p<0.001) had higher odds of leaving against medical advice. The findings from this study identified ED outcomes among high-risk cohort. CONCLUSIONS: There were high ED rates among the limited number EDs facilities in rural Nebraska. Rural regions of Nebraska faced workforce shortages and had high numbers of ED visits at relatively few accessible EDs. CLINICAL IMPLICATIONS: Customised rural-centric public health programmes, which are based in clinical settings, can encourage patients to adhere to ED-treatment. Also, increasing the availability of BH workforce (either via telehealth or part-time presence) in rural areas can alleviate the problem and reduce ED revisits.

Moral Controversy and Working with Colleagues with a Shared Ethical/Moral Outlook: A National Survey of US Primary Care Physicians.

OBJECTIVES: This study assesses physicians' attitudes on the importance of working with colleagues who share the same ethical or moral outlook regarding morally controversial healthcare practices and examines the association of physicians' religious and spiritual characteristics with these attitudes. METHODS: We conducted a secondary data analysis of a 2009 national survey that was administered to a stratified random sample of 1504 US primary care physicians (PCPs). In that dataset, physicians were asked: "For you personally, how important is it to work with colleagues who share your ethical/moral outlook regarding morally controversial health care practices?" We examined associations between physicians' religious/spiritual characteristics and their attitudes toward having a shared ethical/moral outlook with colleagues. RESULTS: Among eligible respondents, the response rate was 63% (896/1427). Overall, 69% of PCPs indicated that working with colleagues who share their ethical/moral outlook regarding morally controversial healthcare practices was either very important (23%) or somewhat important (46%). Physicians who were more religious were more likely than nonreligious physicians to report that a shared ethical/moral outlook was somewhat/very important to them (P < 0.001 for all measures of religiosity, including religious affiliation, attendance at religious services, intrinsic religiosity, and importance of religion as well as spirituality). Physicians with a high sense of calling were more likely than those with a low sense of calling to report a high importance of having a shared ethical/moral outlook with colleagues regarding morally controversial healthcare practices (multivariate odds ratio 2.5, 95% confidence interval 1.5-4.1). CONCLUSIONS: In this national study of PCPs, physicians who identified as religious, spiritual, or having a high sense of calling were found to place a stronger emphasis on the importance of shared ethical/moral outlook with work colleagues regarding morally controversial healthcare practices. Moral controversy in health care may pose a particular challenge for physicians with lower commitments to theological pluralism.

The Evolving Management of Aortic Valve Disease: 5-Year Trends in SAVR, TAVR, and Medical Therapy.

Aortic stenosis (AS) and regurgitation (AR) may be treated with surgical aortic valve replacement (SAVR), transcatheter AVR (TAVR), or medical therapy (MT). Data are lacking regarding the usage of SAVR, TAVR, and MT for patients hospitalized with aortic valve disease and the characteristics of the patients and hospitals associated with each therapy. From the Nationwide Readmissions Database, we determined utilization trends for SAVR, TAVR, and MT in patients with aortic valve disease admitted from 2012 to 2016 for valve replacement, heart failure, unstable angina, non-ST-elevation myocardial infarction, or syncope. We also performed multinomial logistic regressions to investigate associations between patient and hospital characteristics and treatment. Among 366,909 patients hospitalized for aortic valve disease, there was a 48.1% annual increase from 2012 through 2016. Overall, 19.9%, 6.7%, and 73.4% of patients received SAVR, TAVR, and MT, respectively. SAVR decreased from 21.9% in 2012 to 18.5% in 2016, whereas TAVR increased from 2.6% to 12.5%, and MT decreased from 75.5% to 69.0%. Older age, female sex, greater severity of illness, more admission diagnoses, not-for-profit hospitals, large hospitals, and urban teaching hospitals were associated with greater use of TAVR. In multivariable analysis, likelihood of TAVR relative to SAVR increased 4.57-fold (95% confidence interval 4.21 to 4.97). TAVR has increased at the expense of both SAVR and MT, a novel finding. However, this increase in TAVR was distributed inequitably, with certain patients more likely to receive TAVR certain hospitals more likely to provide TAVR. With the expected expansion of indications, inequitable access to TAVR must be addressed.

Post-Discharge Services for Different Diagnoses Than Index Hospitalization Predict Decreased 30-Day Readmissions Among Medicare Beneficiaries.

BACKGROUND: Efforts to reduce hospital readmissions include post-discharge interventions related to the illness treated during the index hospitalization (IH). These efforts may be inadequate because readmissions are precipitated by a wide range of health conditions unrelated to the primary diagnosis of the IH. OBJECTIVE: To investigate the relationship between post-discharge health services utilization for the same or a different diagnosis than the IH and unplanned 30-day readmission. DESIGN AND PARTICIPANTS: The study sample included 583,199 all-cause IHs among 2014 Medicare fee-for-service beneficiaries. For all-cause IH, as well as individually for heart failure, myocardial infarction, and pneumonia IH, we used multivariable logistic regressions to investigate the association between post-discharge services utilization and readmission. MAIN MEASURES: The outcome was unplanned 30-day readmission. Primary independent variables were post-discharge services utilization, including institutional outpatient, office-based primary care, office-based specialist, office-based non-physician practitioner, emergency department, home health care, and skilled nursing facility providers. KEY RESULTS: Among all-cause IH, 11.7% resulted in unplanned 30-day readmissions, and only 18.1% of readmissions occurred for the same primary diagnosis as IH. A substantial majority of post-discharge health services were utilized for a primary diagnosis differing from IH. Compared with no visit, institutional outpatient visits for the same primary diagnosis as IH (odds ratio [OR], 0.33; 95% confidence interval [CI], 0.31-0.34) and for a different primary diagnosis than IH (OR, 0.36; 95% CI, 0.35-0.37) were similarly strongly associated with decreased unplanned 30-day readmission. Primary care physician, specialist, non-physician practitioner, and home health care showed similar patterns. IH for heart failure, myocardial infarction, and pneumonia manifested similar patterns to all-cause IH both in terms of post-discharge services utilization and in terms of its impact on readmission. CONCLUSIONS: To reduce unplanned 30-day readmission more effectively, discharge planning should include post-discharge services to address health conditions beyond the primary cause of the IH.