Personal, health system, and geosocial disparities in appointment nonadherence at family medicine clinics in southcentral Pennsylvania, United States.

Background: To assess the relationship between patients' demographic, health system-related, and geosocial characteristics and the risk of missed appointments among patients in family medicine practice. Methods: The study was based on a retrospective cross-sectional design using electronic health records and neighborhood-level social determents of health metrics linked by geocoded patients' home address. The study population consisted of patients who had a primary care provider and at least one appointment at 14 family medicine clinics in rural and suburban areas in January-December 2022. Negative binomial regression was utilized to examine the impact of personal, health system, and geosocial effects on the risk of no-shows and same-day cancellations. Results: A total of 258,614 appointments were made from 75,182 patients during the study period, including 7.8% no-show appointments from 20,256 patients. The analysis revealed that individuals in the ethnic minority groups were 1.24-1.65 times more likely to miss their appointments than their White counterpart. Females and English speakers had 14% lower risk for no-show. A significant increase (32%-64%) in the odds of no-shows was found among individuals on Medicaid and uninsured. Persons with prior history of no-shows or same day cancellations were 6%-27% more likely to miss their appointments. The no-show risk was also higher among people living in areas experiencing socioeconomic disadvantage. Conclusion: The risk of missed appointments is affected by personal, health system, and geosocial contexts. Future efforts aiming to reduce no-shows could develop personalized interventions targeting the at-risk populations identified in the analysis.

Breast Cancer Screening During the COVID-19 Pandemic in the United States: Results From Real-World Health Records Data.

PURPOSE: The COVID-19 pandemic abruptly interrupted breast cancer screening, an essential preventive service in primary care. We aimed to evaluate the pandemic's impact on overall and follow-up breast cancer screening using real-world health records data. METHODS: We retrospectively analyzed a cohort of women eligible for breast cancer screening through the study period from January 1, 2017 to February 28, 2022 using TriNetX Research Network data. We examined the temporal trend of monthly screening volume throughout the study period and compared the rate of adherence to follow-up screening within 24 months after the previous screening when the follow-up screening was due in the pre-COVID period vs the COVID period. To account for multiple screenings in the longitudinal data, we applied a logistic regression model using generalized estimating equations with adjustment for individual-level covariates. RESULTS: Among 1,186,669 screening-eligible women, the monthly screening volume temporarily decreased by 80.6% from February to April 2020 and then rebounded to close to pre-COVID levels by June 2020. Yet, the follow-up screening rate decreased from 78.9% (95% CI, 78.8%-79.0%) in the pre-COVID period to 77.7% (95% CI, 77.6%-77.8%) in the COVID period. Multivariate regression analysis also showed a lower adherence to follow-up screening during the COVID period (odds ratio = 0.86; 0.86-0.87) and a greater pandemic impact among women aged 65 years and older and women of non-Hispanic "other" race (Asian, American Indian or Alaska Native, and Native Hawaiian or Other Pacific Islander). CONCLUSIONS: The COVID-19 pandemic had a transient negative effect on breast cancer screening overall and a prolonged negative effect on follow-up screening. It also exacerbated gaps in adherence to follow-up screening, especially among certain vulnerable groups, requiring innovative strategies to address potential health disparities in primary care.

Assessing men with opioid use disorder for testosterone deficiency after the development of symptoms.

OBJECTIVE: Individuals with opioid use disorder (OUD) have reduced life expectancy and inferior outcomes when treated for depression, diabetes, and fractures. Their elevated risk of testosterone deficiency may contribute to all of these relationships, however few individuals prescribed opioids are evaluated with testosterone assays. The purpose of this study is to determine whether patients with opioid use disorder are evaluated for testosterone deficiency after development of a symptom that may merit investigation, such as erectile dysfunction (ED). METHOD: We conducted a retrospective longitudinal cohort study that utilized data from a national database called TriNetX. Patients were eligible for inclusion if they were 20 to 90 years of age, male, and diagnosed with erectile dysfunction. We utilized descriptive statistics and logistic regression to address study aims. RESULTS: Testosterone testing was uncommon for all patients with ED. Among 20,658 patients, it was assessed in 11.2% with OUD and 15.1% without OUD. Among those screened, 40% individuals with OUD and ED had testosterone deficiency. Odds of screening those with OUD were lower than matched controls (RR 0.74). CONCLUSIONS: Individuals with OUD are at increased risk of testosterone deficiency than the general population, but nearly 90% are not evaluated for this condition even after development symptoms. That 40% of individuals assessed were classified as testosterone deficient suggests endocrine disorders may be contributing to increased fracture risk, chronic pain, and severe depression commonly encountered in patients with OUD. Addressing this care gap may reduce morbidity and mortality associated with opioid use disorder.

Integrated pain care models and the importance of aligning stakeholder values.

Sustained widespread deployment of clinically and cost-effective models of integrated pain care could be bolstered by optimally aligning shared stakeholder values.

Assessing the risk of COVID-19 reinfection and severe outcomes among individuals with substance use disorders: a retrospective study using real-world electronic health records.

OBJECTIVE: Despite advancement in vaccines and treatments for COVID-19 over the past 2 years, many concerns remain about reinfection and waning immunity against COVID-19 and its variants, especially among people with substance use disorder (SUD). The study assessed the risk of COVID-19 reinfection and severe illness among adults with SUD and their vaccination status to inform management in this vulnerable population as the pandemic continues. DESIGN: Retrospective cohort study. SETTING: Nationwide electronic health records (TriNetX database) in the USA among adults with COVID-19 infection from January 2020 to June 2022. PARTICIPANTS: Adults (age ≥18 years) who were infected by COVID-19, excluding those who had cancer or lived in nursing homes or palliative care facilities. OUTCOME MEASURES: COVID-19 reinfection was defined as a new diagnosis after 45 days of the initial infection. Logistic regression was applied to assess the OR of COVID-19 reinfection and severe outcomes within 30 day of reinfection for adults with alcohol (AUD), opioid (OUD), cocaine (CUD), stimulant (STUD), cannabis (CAUD) and other use disorders, controlled for demographic and comorbid conditions. RESULTS: The SUD cohort was 13%-29% more likely to be reinfected by COVID-19 and had significantly higher 30-day mortality. Adults with AUD, STUD and OUD were at greater risks (adjusted ORs, AORs=1.69-1.86) of emergency department, hospital and intensive care admissions after 30 days of reinfection. Individuals with SUD and multiple vaccines doses were associated with decreased risks of worse COVID-19 outcomes. Lower COVID-19 reinfection rates (AORs=0.67-0.84) were only found among individuals with AUD, CUD or CAUD who had COVID-19 vaccination. CONCLUSIONS: Individuals with SUD had greater risks of COVID-19 reinfection and poor outcomes, especially those with OUD, STUD and AUD. Multiple vaccinations are recommended to reduce severe illness after COVID-19 reinfection in the SUD population.

Opioid dose risk, clinician and patient characteristics, and adherence to opioid prescribing recommendations in chronic non-cancer pain.

OBJECTIVE: This study aims to assess associations between morphine-equivalent daily dose (MEDD) of opioids, clinician and patient characteristics, and prescriber adherence to guidelines for long-term opioid therapy (LTOT) in chronic noncancer pain (CNCP) and to elucidate potential relationships associated with increased-risk opioid prescribing. DESIGN: Retrospective cross-sectional study. SETTING: Academic health system's 33 primary care clinics. PATIENTS: Adults (≥18 years old) prescribed LTOT (10 + outpatient prescriptions in the past year) for CNCP. MAIN OUTCOME MEASURE(S): Electronic health record data on prescribed opioids (for MEDD), clinician/patient characteristics, and adherence rates to LTOT guideline-concordant recommendations. RESULTS: A total of 2,738 patients were eligible, 61.6 percent Lower, 15.7 percent Moderate, and 22.7 percent Higher Risk MEDD (<50, 50-89, and ≥90 mg/day, respectively). Higher MEDD correlated (p < 0.001) with Medicare insurance, current cigarette smoking, higher pain intensity and interference scores, and the presence of opioid use disorder diagnoses. Male clinicians more frequently prescribed (p < 0.001) and male patients were more likely to be prescribed (p < 0.001) higher MEDD compared to their female counterparts. Higher Risk MEDD was associated with higher coprescribed benzodiazepines (p = 0.015), lower depression screening (p = 0.048), urine drug testing (p = 0.003), comparable active treatment agreement (p = 0.189), opioid misuse risk screening (p = 0.619), and prescription drug monitoring checks (p = 0.203). CONCLUSIONS: This study documented that higher MEDD was associated with risks of worse health outcomes without improved adherence to opioid prescribing guideline recommendations. Enhanced clinician awareness of factors associated with MEDD has the potential to mitigate LTOT risks and improve overall patient care.

Do prescription stimulants increase risk of Parkinson's disease among adults with attention-deficit hyperactivity disorder? A retrospective cohort study.

BACKGROUND: Parkinson's disease (PD) is a common neurodegenerative disorder in older adults that is associated with neuroinflammation, oxidative stress, and characterized by loss of dopaminergic cells. Illicit stimulants increase oxidative stress and are associated with increased risk of PD. Prescription stimulants are similar in mechanism to illicit stimulants, yet their influence on PD is not well described. This study aims to determine if prescription stimulants influence risk of PD among older adults with attention-deficit and hyperactivity disorder (ADHD). METHODS: We implemented a retrospective observational cohort design utilizing the TriNetX database which sources from the electronic health records of 57 healthcare organizations. Inclusion criteria were ADHD diagnosis and age ≥50. Those exposed to stimulants and the unexposed controls were matched based on demographics and known risk factors for PD. The outcome of interest was the incidence of PD over a 30-year follow-up period. We utilized TriNetX software for hazard ratio (HR) analysis. RESULTS: Among the 59,471 individuals treated with prescription stimulants 131 of them developed PD, and there were 272 individuals who developed PD that were not prescribed stimulants. This analysis yielded a HR of 0.419 (HR = 0.419 [95% CI 0.34, 0.516], P = 0.0013). CONCLUSION: Illicit stimulants are associated with increased risk of PD, but this study suggests prescribed stimulants may not impart that same risk. The reduced risk in this cohort may be due to protection from illicit substance use and oxidative stress, however additional study exploring the relationship between prescription stimulants and PD is warranted.

Assessing Risks of Early Childhood Caries in Primary Care Practice Using Electronic Health Records and Neighborhood Data.

CONTEXT: Early childhood caries (ECC) is a persistent public health challenge, affecting more than 56% of US toddlers and preschool-aged children. Despite this, ECC is largely preventable with routine oral hygiene practices, diet, and application of topical fluoride. OBJECTIVE: This study assessed the utilization of preventive oral health care in primary care practices and evaluated the variation in patient characteristic and geographic disparities. DESIGN: We conducted a retrospective study using electronic health records (EHRs) over a 2-year period. Patients' home addresses were geocoded and linked to census-based neighborhood statistics and fluoridated water accessibility. Multiple logistic regression modeling was used to assess the risk of ECC in patients with fluoride preventive care, controlled for demographics, comorbid conditions, and neighborhood risk factors. PARTICIPANTS: Patients aged 6 to 71 months who had primary care providers at family medicine and general pediatric clinics in a large academic medical center. MAIN OUTCOME MEASURE: The presence of dental caries based on diagnoses in EHRs. RESULTS: The study consisted of 10 836 patients: 17% treated with topical fluoride varnish (TFV), 12% prescribed oral fluoride supplement, 6.1% with both TFV and supplement, and 64% without fluoride treatment. Patients with fluoride treatment were 24% to 53% less likely to have ECC. Children living in rural and nonfluoridated water communities had 1.7 to 1.8 times greater risk of developing ECC. Minority, under/uninsured, and low-income patients also were at an increased risk of ECC. CONCLUSION: Despite continuing efforts to improve access to dental care for vulnerable populations, substantial disparities remain among socioeconomically disadvantaged children. To address dental care shortage, primary care clinicians should serve as the safety net to care for vulnerable and underserved children who have no or limited access to oral health services. Future research into the collaboration between primary care and dental providers at the level of both practice and professional education should be considered.

Gardening Is Associated With Better Cardiovascular Health Status Among Older Adults in the United States: Analysis of the 2019 Behavioral Risk Factor Surveillance System Survey.

BACKGROUND: Gardening benefits health in older adults, but previous studies have limited generalizability or do not adequately adjust for sociodemographic factors or physical activity (PA). OBJECTIVE: We examined health outcomes, fruits and vegetables (F&V) intake, and 10-year mortality risk among gardeners and exercisers compared with nonexercisers. DESIGN: Cross-sectional data of noninstitutionalized US adults in the 2019 Behavioral Risk Factor Surveillance System was collected via landline and cellular phone survey. PARTICIPANTS/SETTING: Adults 65 years and older reporting any PA (n = 146,047) were grouped as gardeners, exercisers, or nonexercisers. MAIN OUTCOME MEASURES: Outcomes included cardiovascular disease (CVD) risk factors, mental and physical health, F&V intake, and 10-year mortality risk. STATISTICAL ANALYSES: Summary statistics were calculated and adjusted logistic regression models were conducted to calculate adjusted odds ratios (aORs) and 95% CIs, accounting for the complex survey design. RESULTS: The sample included gardeners (10.2%), exercisers (60.0%), and nonexercisers (30.8%). Gardeners, compared with nonexercisers, had significantly lower odds of reporting all studied health outcomes and higher odds of consuming 5 or more F&V per day (CVD: aOR 0.60, 95% CI 0.53 to 0.68; stroke: aOR 0.55, 95% CI 0.47 to 0.64; heart attack: aOR 0.63, 95% CI 0.55 to 0.73, high cholesterol: aOR 0.86, 95% CI 0.79 to 0.93; high blood pressure: aOR 0.74, 95% CI 0.68 to 0.81; diabetes: aOR 0.51, 95% CI 0.46 to 0.56; body mass index ≥25: aOR 0.74, 95% CI 0.68 to 0.80; poor mental health status: aOR 0.50, 95% CI 0.43 to 0.59; poor physical health status: aOR 0.35, 95% CI 0.31 to 0.39; 5 or more F&V per day: aOR 1.56, 95% CI 1.40 to 1.57; high 10-year mortality risk: aOR 0.39, 95% CI 0.36 to 0.42). Male and female gardeners had significantly lower odds of reporting diabetes even when compared with exercisers. CONCLUSIONS: Among adults 65 years and older, gardening is associated with better CVD health status, including lower odds of diabetes. Future longitudinal or interventional studies are warranted to determine whether promoting gardening activities can be a CVD risk reduction strategy.

External Validation of the COVID-NoLab and COVID-SimpleLab Prognostic Tools.

Our objective was to externally validate 2 simple risk scores for mortality among a mostly inpatient population with COVID-19 in Canada (588 patients for COVID-NoLab and 479 patients for COVID-SimpleLab). The mortality rates in the low-, moderate-, and high-risk groups for COVID-NoLab were 1.1%, 9.6%, and 21.2%, respectively. The mortality rates for COVID-SimpleLab were 0.0%, 9.8%, and 20.0%, respectively. These values were similar to those in the original derivation cohort. The 2 simple risk scores, now successfully externally validated, offer clinicians a reliable way to quickly identify low-risk inpatients who could potentially be managed as outpatients in the event of a bed shortage. Both are available online (https://ebell-projects.shinyapps.io/covid_nolab/ and https://ebell-projects.shinyapps.io/COVID-SimpleLab/).

Provider and patient sex disparities in opioid prescribing and patient outcomes.

OBJECTIVE: To assess sex disparities in opioid prescribing practices and patient outcomes. DESIGN: A retrospective cross-sectional study. SETTING: Thirty-three primary care clinics in an academic health system. PARTICIPANTS: 2,738 adults prescribed 10+ outpatient opioid prescriptions within 12 months. MAIN OUTCOME MEASURE(S): Patient and primary care provider (PCP) sexbased differences in clinical outcomes, opioid prescribing, and rates of adherence to guideline-concordant opioid prescribing practices. RESULTS: Female PCPs were more likely (p < 0.001) to prescribe lower morphineequivalent daily dose (MEDD) of opioids and complete risk assessment for opioid misuse than male PCPs. PCPs did not differ by sex in adherence rates to controlled substance agreements, urine drug, depression screening, or opioid-benzodiazepine coprescribing. Female patients were more likely (all p ≤ 0.01) to be screened for opioid misuse, treated with lower MEDD, receive opioid-benzodiazepine coprescriptions, have higher pain interference, anxiety and depression diagnoses, and have an overdose diagnosis; they were less likely (all p < 0.001) to report alcohol use or have an alcohol use disorder diagnosis and utilized health care at higher rates than male patients. CONCLUSIONS: Sex differences were found in clinician opioid-prescribing practices and adherence to opioid prescribing guidelines and patient characteristics associated with long-term opioid therapy. Strategies to identify sex-related disparities and enhance guideline-concordant opioid prescribing and monitoring could contribute to improved patient care, and clinical and safety outcomes.

Patients' View of Their Primary Care Telemedicine During the COVID-19 Pandemic and Implications for Future Integration: A Multimethod Study.

INTRODUCTION: Telemedicine has become an integral part of primary care since the COVID-19 pandemic. This paper reports patients' assessments of their early telemedicine visits. METHODS: Adult primary care patients who had a telemedicine visit were identified from electronic medical records of a large Midwestern health system and randomly invited to participate in semistructured interviews. Participants compared telemedicine visits (audio and video) to face-to-face visits on measures of satisfaction and answered open-ended questions about the technology, primary care relationships, and ongoing use of telemedicine. Interviews were recorded and responses transcribed for qualitative analysis. RESULTS: The quantitative results revealed participants valued convenience and judged telemedicine visits "about the same" as office visits on satisfaction measures. Participants were largely willing to have another telemedicine visit but were concerned with the technological challenges and lack of physical examination. The qualitative analysis found most participants reported that telemedicine care was best with a known clinician. Further, they judged telemedicine to be best for follow-ups and simple or single problems and believed it should be balanced with face-to-face visits. CONCLUSIONS: Participants expect telemedicine will continue and have clearly articulated their telemedicine preferences. These preferences include telemedicine with a known clinician, the visits that they judged most appropriate for telemedicine, the need to balance telemedicine with face-to-face visits, and assured technologic access. The need for quality measures beyond patient satisfaction and the role of team-based telemedicine care emerged as areas for further research.

Risks of Severe COVID-19 Outcomes Among Patients With Diabetic Polyneuropathy in the United States.

CONTEXT: Diabetic neuropathy (DN) affects more than 50% of diabetic patients who are also likely to have compromised immune system and respiratory function, both of which can make them susceptible to the SARS-CoV-2 virus. OBJECTIVE: To assess the risk of severe COVID-19 illness among adults with DN, compared with those with no DN and those with no diabetes. SETTING: The analysis utilized electronic health records from 55 US health care organizations in the TriNetX research database. DESIGN: A retrospective cohort study. PARTICIPANTS: The analysis included 882 650 adults diagnosed with COVID-19 in January 2020 to June 2021, including 16 641 with DN, 81 329 with diabetes with no neuropathy, and 784 680 with no diabetes. OUTCOME MEASURES: The presence of health care utilization (admissions to emergency department, hospital, intensive care unit), 30-day mortality, clinical presentation (cough, fever, hypoxemia, dyspnea, or acute respiratory distress syndrome), and diagnostic test results after being infected affected by COVID-19. RESULTS: The DN cohort was 1.19 to 2.47 times more likely than the non-DN cohorts to utilize care resources, receive critical care, and have higher 30-day mortality rates. Patients with DN also showed increased risk (1.13-2.18 times) of severe symptoms, such as hypoxemia, dyspnea, and acute respiratory distress syndrome. CONCLUSIONS: Patients with DN had a significantly greater risk of developing severe COVID-19-related complications than those with no DN. It is critical for the public health community to continue preventive measures, such as social distancing, wearing masks, and vaccination, to reduce infection rates, particularly in higher risk groups, such as those with DN.

Trends in characteristics of the recipients of new prescription stimulants between years 2010 and 2020 in the United States: An observational cohort study.

Background: Stimulant prescriptions increased by 250% in the United States from 2006-2016 while diagnoses for ADHD minimally increased. There is insufficient data regarding who may be the recipients of these new stimulant prescriptions and safety of stimulants have come under scrutiny in some populations. We aim to describe trends in stimulant prescriptions across biopsychosocial patient level factors between 2010 and 2020. Methods: We applied a retrospective observational cohort design utilizing electronic health records from 52 healthcare organizations sourced from the TriNetX research network database in the United States. We assessed new stimulant prescriptions across biopsychosocial variables for recipients of prescriptions. We utilized linear regression to assess longitudinal trends of all participants and also conducted an age stratified logistic regression analysis. Findings: There was an increase in stimulants to people categorized as white (OR 1.24 CI 1.20-1.28), female (OR 1.28 CI 1.23-1.31), and to those with diagnosed anxiety disorders (OR 1.39 CI 1.35-1.44) as well as obesity (OR 1.34 CI 1.28-1.41). The average age of recipients increased throughout the study, and among people sixty-five and older, there was an increase in prescriptions to people with multiple cardiovascular risk factors. Interpretation: Prescription stimulant dispensing may have liberalized during the study period in some demographics as a greater number of new prescriptions were dispensed to individuals with risk of adverse outcomes (i.e. older individuals, obese individuals, and geriatric patients with CV risk factors) between 2010 and 2020. Similar trends in prescription medications were witnessed through the opioid epidemic and warrant attention given concerning trends with illicit stimulants. Additional research that investigates patient and provider motivation for stimulant prescriptions, as well as risk perception of stimulants, may be warranted. Funding: This study was made possible by institutional resources at Penn State Hershey Medical Center.

Treatment with stimulants and the risk of COVID-19 complications in adults with ADHD.

Adults with attention deficit hyperactivity disorder (ADHD) have shown higher infection rates and worse outcomes from COVID-19. Stimulant medications are prescribed as the first-line treatment for ADHD in adults and mitigate risk of negative ADHD-related health outcomes, but little is known about the association between stimulant medications and COVID-19 outcomes. The objective of this study was to assess the risks of severe COVID-19 outcomes among people with ADHD who were prescribed stimulant medications versus those who were not. This retrospective cohort study used electronic health records in the TriNetX research database. We assessed records of adults with ADHD diagnosed with COVID-19 between January 1, 2020 and June 30, 2021. The stimulant cohort consisted of 28,011 people with at least one stimulant prescription; the unmedicated cohort comprised 42,258 people without prescribed stimulants within 12 months prior to their COVID infection. Multiple logistic regression modeling was utilized to assess the presence of critical care services or death within 30 days after the onset of COVID diagnoses, controlling for patient demographics, and comorbid medical and mental health conditions. The stimulant cohort was less likely to utilize emergency department, hospital, and intensive care services than the unmedicated cohort, and had significantly lower 30-day mortality. Further research, including prospective studies, is needed to confirm and refine these findings.

Disparities in Use of Patient Portals Among Adults in Family Medicine.

OBJECTIVE: This study examined patient portal utilization by analyzing the pattern of time and feature use of patients, and thus to identify functionalities of portal use and patient characteristics that may inform future strategies to enhance communication and care coordination through online portals. METHODS: We conducted a retrospective study of patients at 18 family medicine clinics over a 5-year period using access log records in the electronic health record database. Dimensionality reduction analysis was applied to group portal functionalities into 4 underlying feature domains: messaging, health information management, billing/insurance, and resource/education. Negative binomial regression analysis was used to evaluate how patient and practice characteristics affected the use of each feature domain. RESULTS: Patients with more chronic conditions, lab tests, or prescriptions generally showed greater patient portal usage. However, patients who were male, elderly, in minority groups, or living in rural areas persistently had lower portal usage. Individuals on public insurance were also less likely than those on commercial insurance to use patient portals, although Medicare patients showed greater portal usage on health information management features, and uninsured patients had greater usage on viewing resource/education features. Having Internet access only affected the use of messaging features. CONCLUSION: Efforts to enroll patients in online portals do not guarantee patients will use the portals to manage their health. When considering the use of patient portals for improving telehealth, clinicians need to be aware of technological, socioeconomic, and cultural challenges faced by their patients.

Transitioning from insulin to dipeptidyl-peptidase 4 (DPP-4) inhibitors for type 2 diabetes.

Insulin administration is time intensive and costly in facility staffing. When we started nursing home patients with type 2 diabetes (T2D) on DPP-4 inhibitors, we tapered insulin when finger stick blood sugar levels dropped to <200 mg/dL. Of 34 patients we were able to stop mealtime insulin in 28 (82%) and stop all insulin in 20 (59%). On average, hemoglobin A1c (HbA1c) decreased 0.5% and weight by 2.8 pounds. Among the 20 who stopped all insulin, HbA1c improved in 11 on average 1% (p=0.02), and weight decreased in 11 on average 4.1 pounds (p=0.66). 12 patients were switched in one day because of a low insulin dose or low HbA1c Tapering duration in the other 8 ranged from 10-727 days with an insulin dose of 28 to 84 units daily. Larger studies are needed to confirm our findings, develop a protocol for tapering insulin, and measure hypoglycemia, comfort and cost.

Development and Validation of a Two-Step Predictive Risk Stratification Model for Coronavirus Disease 2019 In-hospital Mortality: A Multicenter Retrospective Cohort Study.

Objectives: An accurate prognostic score to predict mortality for adults with COVID-19 infection is needed to understand who would benefit most from hospitalizations and more intensive support and care. We aimed to develop and validate a two-step score system for patient triage, and to identify patients at a relatively low level of mortality risk using easy-to-collect individual information. Design: Multicenter retrospective observational cohort study. Setting: Four health centers from Virginia Commonwealth University, Georgetown University, the University of Florida, and the University of California, Los Angeles. Patients: Coronavirus Disease 2019-confirmed and hospitalized adult patients. Measurements and Main Results: We included 1,673 participants from Virginia Commonwealth University (VCU) as the derivation cohort. Risk factors for in-hospital death were identified using a multivariable logistic model with variable selection procedures after repeated missing data imputation. A two-step risk score was developed to identify patients at lower, moderate, and higher mortality risk. The first step selected increasing age, more than one pre-existing comorbidities, heart rate >100 beats/min, respiratory rate ≥30 breaths/min, and SpO2 <93% into the predictive model. Besides age and SpO2, the second step used blood urea nitrogen, absolute neutrophil count, C-reactive protein, platelet count, and neutrophil-to-lymphocyte ratio as predictors. C-statistics reflected very good discrimination with internal validation at VCU (0.83, 95% CI 0.79-0.88) and external validation at the other three health systems (range, 0.79-0.85). A one-step model was also derived for comparison. Overall, the two-step risk score had better performance than the one-step score. Conclusions: The two-step scoring system used widely available, point-of-care data for triage of COVID-19 patients and is a potentially time- and cost-saving tool in practice.

Cardiovascular Outcomes Among Older Individuals With Depression Prescribed Amphetamines: A Retrospective Cohort Study.

BACKGROUND: Prescription amphetamines are utilized for treatment of depression in older adults, yet cardiovascular risks in this population are not well described. The purpose of this study is to evaluate risk of cardiovascular events among adults aged 65 and older with depression who were prescribed amphetamines. METHODS: We conducted a retrospective matched cohort study utilizing the TriNetx database and statistical software. The 1:1 propensity score matching technique was performed using logistic regression to balance the baseline characteristics of the population. Inclusion criteria were a diagnosis of depression and age 65 years and older. We excluded individuals with an adverse cardiovascular event or diagnosis of attention deficit and hyperactivity disorder prior to enrollment. Individuals were followed from January 1, 2018 to December 31, 2020. Those prescribed an amphetamine were considered exposed and others served as controls. We used descriptive statistics and calculated risk ratios to assess the relationship between amphetamine prescriptions and cardiovascular events in these cohorts. RESULTS: There were 4 434 included in the exposed cohort and 4 434 matched controls in the unexposed group. The cohort exposed to amphetamines had higher high-density lipoprotein along with lower low-density lipoprotein, total cholesterol, hemoglobin A1C, systolic blood pressure, and body mass index than the control group, but increased risk of cardiovascular events (risk ratio: 8.9; 95% confidence interval: 6.39, 12.48). CONCLUSIONS: Amphetamines offer potential benefits to people with depression; however, these data suggest increased risk of cardiovascular events among older individuals. Additional research is warranted to fully characterize risk among subpopulations of older adults and inform patient-provider decision making.