Kelly K. Richardson

Hospital episodes and physician visits: the concordance between self-reports and medicare claims.

Background:Health services use typically is examined using either self-reports or administrative data, but the concordance between the 2 is not well established. Objective:We evaluated the concordance of hospital and physician utilization data from self-reports and claims data, and identified factors associated with disagreement. Methods:We performed a secondary analysis on linked observational and administrative data. A national sample of 4310 respondents who were 70 years old or older at their baseline interviews was used. Self-reported and Medicare claims-based hospital episodes and physician visits for 12 months before baseline were examined. Kappa statistics were used to evaluate concordance, and multivariable multinomial logistic regression was used to identify factors associated with overreporting (self-reports > claims), underreporting (self-reports < claims), and concordant-reporting (self-reports ∼ claims). Results:The concordance of hospital episodes was high (κ = 0.767 for the 2 × 2 comparison of none vs. some and κ = 0.671 for the 6 × 6 comparison of none, 1, …, 4, or 5 or more), but concordance for physician visits was low (κ = 0.255 for the 2 × 2 comparison of none versus some and κ = 0.351 for the 14 × 14 comparison of none, 1, ..., 12, and 13 or more). Multivariable multinomial logistic regression indicated that over-, under-, and concordant-reporting of hospital episodes was significantly associated with gender, alcohol consumption, arthritis, cancer, heart disease, psychologic problems, lower body functional limitations, self-rated health, and depressive symptoms. Over-, under-, and concordant-reporting of physician visits were significantly associated with age, gender, race, living alone, veteran status, private health insurance, arthritis, cancer, diabetes, hypertension, heart disease, lower body functional limitations, and poor memory. Conclusions:Concordance between self-reported and claims-based hospital episodes was high, but concordance for physician visits was low. Factors significantly associated with bidirectional (over- and underreporting) and unidirectional (over- or underreporting) error patterns were detected. Therefore, caution is advised when drawing conclusions based on just one physician visit data source.

The “Dark Side” of the Strength of Weak Ties: The Diffusion of Suicidal Thoughts

Granovetters theory on the strength of weak ties motivates hypotheses on the diffusive nature of suicidal thoughts in the friendship networks of adolescents. Using data from the National Longitudinal Study of Adolescent Health, the effects of friends-of-friends attempting suicide on the suicidal thoughts of respondents are estimated. A focus on friends-of-friends permits a test of the weakties thesis because respondents are indirectly linked to friends-of-friends by “open ties” that are both structurally weak and used as bridges. Results for “at-risk” respondents—or those with certain behaviors, statuses, and experiences that create psychological predispositions to suicide—are consistent with Granovetters theory and thus reveal the “dark side” of the strength of weak ties as at-risk respondents are more likely to seriously think about committing suicide when a friend-of-a-friend attempts suicide, controlling for past suicidal thoughts by the respondent and attempts by friends, family, and students in the respondents school, among other control factors. Barriers to diffusion are also considered.

Recent Hospitalization and the Risk of Hip Fracture Among Older Americans

BACKGROUND We identified hip fracture risks in a prospective national study. METHODS Baseline (1993-1994) interview data were linked to Medicare claims for 1993-2005. Participants were 5,511 self-respondents aged 70 years and older and not in managed Medicare. ICD9-CM 820.xx (International Classification of Diseases, 9th Edition, Clinical Modification) codes identified hip fracture. Participants were censored at death or enrollment into managed Medicare. Static risk factors included sociodemographic, socioeconomic, place of residence, health behavior, disease history, and functional and cognitive status measures. A time-dependent marker reflecting postbaseline hospitalizations was included. RESULTS A total of 495 (8.9%) participants suffered a postbaseline hip fracture. In the static proportional hazards model, the greatest risks involved age (adjusted hazard ratios [AHRs] of 2.01, 2.82, and 4.91 for 75-79, 80-84, and > or =85 year age groups vs those aged 70-74 years; p values <.001), sex (AHR = 0.45 for men vs women; p < .001), race (AHRs of 0.37 and 0.46 for African Americans and Hispanics vs whites; p values <.001 and <.01), body mass (AHRs of 0.40, 0.77, and 1.73 for obese, overweight, and underweight vs normal weight; p values <.001, <.05, and <.01), smoking status (AHRs = 1.49 and 1.52 for current and former smokers vs nonsmokers; p values <.05 and <.001), and diabetes (AHR = 1.99; p < .001). The time-dependent recent hospitalization marker did not alter the static model effect estimates, but it did substantially increase the risk of hip fracture (AHR = 2.51; p < .001). CONCLUSIONS Enhanced discharge planning and home care for non-hip fracture hospitalizations could reduce subsequent hip fracture rates.

Racial Segregation and Disparities in Health Care Delivery: Conceptual Model and Empirical Assessment

OBJECTIVE This study examines two dimensions of racial segregation across hospitals, using a disease for which substantial disparities have been documented. DATA SOURCES Black (n=32,289) and white (n=244,042) patients 67 years and older admitted for acute myocardial infarction during 2004-2005 in 105 hospital markets were identified from Medicare data. Two measures of segregation were calculated: Dissimilarity (i.e., dissimilar distribution by race across hospitals), and Isolation (i.e., racial isolation within hospitals). For each measure, markets were categorized as having low, medium, or high segregation. STUDY DESIGN The relationship of hospital segregation to residential segregation and other market characteristics was evaluated. Cox proportional hazards regression was used to evaluate disparities in the use of revascularization within 90 days by segregation level. RESULTS Agreement of segregation category based on Dissimilarity and Isolation was poor (kappa=0.12), and the relationship of disparities in revascularization to segregation differed by measure. The hazard of revascularization for black relative to white patients was lowest (i.e., greatest disparity) in markets with low Dissimilarity, but it was unrelated to Isolation. CONCLUSIONS Significant racial segregation across hospitals exists in many U.S. markets, although the magnitude and relationship to disparities depends on definition. Dissimilar distribution of race across hospitals may reflect divergent cultural preferences, social norms, and patient assessments of provider cultural competence, which ultimately impact utilization.

The use of chiropractors by older adults in the United States

BackgroundIn a nationally representative sample of United States Medicare beneficiaries, we examined the extent of chiropractic use, factors associated with seeing a chiropractor, and predictors of the volume of chiropractic use among those having seen one.MethodsWe performed secondary analyses of baseline interview data on 4,310 self-respondents who were 70 years old or older when they first participated in the Survey on Assets and Health Dynamics Among the Oldest Old (AHEAD). The interview data were then linked to their Medicare claims. Multiple logistic and negative binomial regressions were used.ResultsThe average annual rate of chiropractic use was 4.6%. During the four-year period (two years before and two years after each respondents baseline interview), 10.3% had one or more visits to a chiropractor. African Americans and Hispanics, as well as those with multiple depressive symptoms and those who lived in counties with lower than average supplies of chiropractors were much less likely to use them. The use of chiropractors was much more likely among those who drank alcohol, had arthritis, reported pain, and were able to drive. Chiropractic services did not substitute for physician visits. Among those who had seen a chiropractor, the volume of chiropractic visits was lower for those who lived alone, had lower incomes, and poorer cognitive abilities, while it was greater for the overweight and those with lower body limitations.ConclusionChiropractic use among older adults is less prevalent than has been consistently reported for the United States as a whole, and is most common among Whites, those reporting pain, and those with geographic, financial, and transportation access.

Association of Evidence-Based Care Processes With Mortality in Staphylococcus aureus Bacteremia at Veterans Health Administration Hospitals, 2003-2014

Importance Staphylococcus aureus bacteremia is common and frequently associated with poor outcomes. Evidence indicates that specific care processes are associated with improved outcomes for patients with S aureus bacteremia, including appropriate antibiotic prescribing, use of echocardiography to identify endocarditis, and consultation with infectious diseases (ID) specialists. Whether use of these care processes has increased in routine care for S aureus bacteremia or whether use of these processes has led to large-scale improvements in survival is unknown. Objective To examine the association of evidence-based care processes in routine care for S aureus bacteremia with mortality. Design, Setting, and Participants This retrospective observational cohort study examined all patients admitted to Veterans Health Administration (VHA) acute care hospitals who had a first episode of S aureus bacteremia from January 1, 2003, through December 31, 2014. Exposures Use of appropriate antibiotic therapy, echocardiography, and ID consultation. Main Outcomes and Measures Thirty-day all-cause mortality. Results Analyses included 36 868 patients in 124 hospitals (mean [SD] age, 66.4 [12.5] years; 36 036 [97.7%] male), including 19 325 (52.4%) with infection due to methicillin-resistant S aureus and 17 543 (47.6%) with infection due to methicillin-susceptible S aureus. Risk-adjusted mortality decreased from 23.5% (95% CI, 23.3%-23.8%) in 2003 to 18.2% (95% CI, 17.9%-18.5%) in 2014. Rates of appropriate antibiotic prescribing increased from 2467 (66.4%) to 1991 (78.9%), echocardiography from 1256 (33.8%) to 1837 (72.8%), and ID consultation from 1390 (37.4%) to 1717 (68.0%). After adjustment for patient characteristics, cohort year, and other care processes, receipt of care processes was associated with lower mortality, with adjusted odds ratios of 0.74 (95% CI, 0.68-0.79) for appropriate antibiotics, 0.73 (95% CI, 0.68-0.78) for echocardiography, and 0.61 (95% CI, 0.56-0.65) for ID consultation. Mortality decreased progressively as the number of care processes that a patient received increased (adjusted odds ratio for all 3 processes compared with none, 0.33; 95% CI, 0.30-0.36). An estimated 57.3% (95% CI, 48.4%-69.9%) of the decrease in mortality between 2003 and 2014 could be attributed to increased use of these evidence-based care processes. Conclusions and Relevance Mortality associated with S aureus bacteremia decreased significantly in VHA hospitals, and a substantial portion of the decreasing mortality may have been attributable to increased use of evidence-based care processes. The experience in VHA hospitals demonstrates that increasing application of these care processes may improve survival among patients with S aureus bacteremia in routine health care settings.

The Effect of a Nationwide Infection Control Program Expansion on Hospital-Onset Gram-Negative Rod Bacteremia in 130 Veterans Health Administration Medical Centers: An Interrupted Time-Series Analysis

BACKGROUND The Veterans Health Administration (VHA) introduced the Methicillin-Resistant Staphylococcus aureus (MRSA) Prevention Initiative in March 2007. Although the initiative has been perceived as a vertical intervention focusing on MRSA, it also expanded infection prevention and control programs and resources. We aimed to assess the horizontal effect of the initiative on hospital-onset (HO) gram-negative rod (GNR) bacteremia. METHODS This retrospective cohort included all patients who had HO bacteremia due to Escherichia coli, Klebsiella species, or Pseudomonas aeruginosa at 130 VHA facilities from January 2003 to December 2013. The effects were assessed using segmented linear regression with autoregressive error models, incorporating autocorrelation, immediate effect, and time before and after the initiative. Community-acquired (CA) bacteremia with same species was also analyzed as nonequivalent dependent controls. RESULTS A total of 11 196 patients experienced HO-GNR bacteremia during the study period. There was a significant change of slope in HO-GNR bacteremia incidence rates from before the initiative (+0.3%/month) to after (-0.4%/month) (P < .01), while CA GNR incidence rates did not significantly change (P = .08). Cumulative effect of the intervention on HO-GNR bacteremia incidence rates at the end of the study period was estimated to be -43.2% (95% confidence interval, -51.6% to -32.4%). Similar effects were observed in subgroup analyses of each species and antimicrobial susceptibility profile. CONCLUSIONS Within 130 VHA facilities, there was a sustained decline in HO-GNR bacteremia incidence rates after the implementation of the MRSA Prevention Initiative. As these organisms were not specifically targeted, it is likely that horizontal components of the initiative contributed to this decline.

Impact of functional limitations and medical comorbidity on subsequent weight changes and increased depressive symptoms in older adults.

Objectives: The primary goal of this study was to determine the effect of the onset of major medical comorbidity and functional decline on subsequent weight change and increased depressive symptoms. Methods: The sample included a prospective cohort of 53 to 63 year olds (n = 10,150) enrolled in the Health and Retirement Study. Separate lagged covariate models for men and women were used to study the impact of functional decline and medical comorbidity on subsequent increases in depressive symptoms and weight change 2 years later. Results: Functional decline and medical comorbidity were individual predictors of subsequent weight changes but not increased depressive symptoms. Most specific incident medical comorbidities or subtypes of functional decline predicted weight changes in both directions. Discussion: The elevated risk of weight gain subsequent to functional decline or onset of medical comorbidities may require the receipt of preventive measures to reduce further weight-related complications.

Development of a prediction rule for methicillin-resistant Staphylococcus aureus and vancomycin-resistant enterococcus carriage in a Veterans Affairs Medical Center population.

A history of hospital admission in the prior year was the most sensitive predictor of methicillin-resistant Staphylococcus aureus or vancomycin-resistant Enterococcus colonization at admission to a Veterans Affairs Medical Center (VAMC) but missed more than one-third of carriers and required screening more than one-half of admitted patients.

A Mixed‐Method Approach to Evaluate a Pharmacist Intervention for Veterans With Hypertension

This paper examines blood pressure (BP) control after 6 months of an intensive pharmacist‐managed intervention in a mixed‐methods randomized controlled trial conducted at the Iowa City Veteran Affairs Health Care System and two community‐based outreach clinics. Patients received the pharmacist intervention for the first 6 months. The study coordinator conducted a summative evaluation with 37 patients 18 to 24 months following the initial 6‐month intervention period. BP was significantly reduced in diabetic patients following an intensive pharmacist intervention (−8.0/−4.0±14.4/9.1 mm Hg systolic/diastolic, P<.001 and P=.001, respectively). BP was reduced even more in nondiabetic patients (−14.0/−5.0±1.9/10.0 mm Hg, P<.001). Medication adherence significantly improved from baseline to 6 months (P=.017). BPs were significantly lower at 6 months following an intensive pharmacist intervention. Patients also expressed a high level of satisfaction with and preference for co‐management of their hypertension, as well as other chronic diseases.