Veerappa K. Chetty

Mental Health Conditions are Associated With Increased Health Care Utilization Among Urban Family Medicine Patients

Purpose: To assess the relationship between the presence of a mental health condition and health care utilization among family medicine patients. Methods: We used the Patient Health Questionnaire plus a posttraumatic stress disorder screen to measure 6 common mental health conditions. In a sample of 367 patients recruited from 3 urban family medicine practices affiliated with Boston University Medical Center, we measured self-reported health care utilization of primary care provider visits, emergency department visits, nonpsychiatric hospitalizations, and outpatient mental health visits. We determined the association between screening positive for the mental health conditions and health care utilization using both multivariable logistic regression and Poisson regression methods while controlling for sex, age, race, income, insurance status, marital status, educational level, and the presence of chronic medical conditions. Results: After controlling for potential confounders, generalized anxiety disorder, panic disorder, and posttraumatic stress disorder were statistically significantly associated with more PCP visits, ED visits, and nonpsychiatric hospitalizations. Neither major nor minor depression were associated with more PCP visits, ED visits, or nonpsychiatric hospitalizations, except that minor depression was associated with 103% increase in PCP visits (P < .001). Alcohol use disorder was associated with 16% fewer PCP visits (P = .01) but 238% more nonpsychiatric hospitalizations (P < .001). Conclusions: After controlling for confounders we found that mental health conditions among a sample of family medicine patients were associated with increased use of ED services, nonpsychiatric hospitalizations, and, to a lesser extent, PCP visits.

Acute care hospital utilization among medical inpatients discharged with a substance use disorder diagnosis.

Objective:Hospital discharge may be an opportunity to intervene among patients with substance use disorders to reduce subsequent hospital utilization. This study determined whether having a substance use disorder diagnosis was associated with subsequent acute care hospital utilization. Methods:We conducted an observational cohort study among 738 patients on a general medical service at an urban, academic, safety-net hospital. The main outcomes were rate and risk of acute care hospital utilization (emergency department visit or hospitalization) within 30 days of discharge. The main independent variable was presence of a substance use disorder primary or secondary discharge diagnosis code at the index hospitalization. Results:At discharge, 17% of subjects had a substance use disorder diagnosis. These patients had higher rates of recurrent acute care hospital utilization than patients without substance use disorder diagnoses (0.63 vs 0.32 events per subject at 30 days, P < 0.01) and increased risk of any recurrent acute care hospital utilization (33% vs 22% at 30 days, P < 0.05). In adjusted Poisson regression models, the incident rate ratio at 30 days was 1.49 (95% confidence interval, 1.12–1.98) for patients with substance use disorder diagnoses compared with those without. In subgroup analyses, higher utilization was attributable to those with drug diagnoses or a combination of drug and alcohol diagnoses, but not to those with exclusively alcohol diagnoses. Conclusions:Medical patients with substance use disorder diagnoses, specifically those with drug use-related diagnoses, have higher rates of recurrent acute care hospital utilization than those without substance use disorder diagnoses.

Post-discharge hospital utilization among adult medical inpatients with depressive symptoms†

BACKGROUND Little evidence exists to determine whether depression predicts hospital utilization following discharge among adult inpatients on a general medical service. OBJECTIVE We aimed to determine whether a positive depression screen during hospitalization is significantly associated with an increased rate of returning for hospital services. DESIGN A secondary analysis was performed using data from 738 English-speaking, hospitalized adults from the Project RED randomized controlled trial (clinicaltrials.gov Identifier: NCT00252057) conducted at an urban academic safety-net hospital. MEASUREMENTS We used the nine-item Patient Health Questionnaire (PHQ-9) depression screening tool to identify patients with depressive symptoms. The primary endpoint was hospital utilization, defined as the number of emergency department (ED) visits plus readmissions within 30 days of discharge. Poisson regression was used to control for confounding variables. RESULTS Of the 738 subjects included in the analysis, 238 (32%) screened positive for depressive symptoms. The unadjusted hospital utilization within 30 days of discharge was 56 utilizations per 100 depressed patients compared with 30 utilizations per 100 non-depressed patients, incident rate ratio (IRR) (confidence interval [CI]), 1.90 (1.51-2.40). After controlling for potential confounders, a higher rate of post-discharge hospital utilization was observed in patients with depressive symptoms compared to patients without depressive symptoms (IRR [CI], 1.73 [1.27-2.36]). CONCLUSIONS A positive screen for depressive symptoms during an inpatient hospital stay is associated with an increased rate of readmission within 30 days of discharge in an urban, academic, safety-net hospital population.

Maternal Hypertension as a Risk Factor for Low Birth Weight Infants: Comparison of Haitian and African-American Women

Background: The rate of low birth weight (LBW) of Black women is more than twice that of White women. This study explores if the rate of LBW differs between Haitian and African-American women with chronic hypertension. Methods: A retrospective cohort study of all Black women self-identified as African-American (n = 12,258) or Haitian (n = 4320) delivering a singleton infant in Massachusetts between 1996 and 2000. Results: Haitian women were more likely than African-American women to have chronic hypertension (2.7% vs. 2.1%, p = 0.006), but had similar rates of preeclampsia (3.1% vs. 3.3%, p = 0.27). The LBW rate was 10% among African-American women and 8.2% among Haitian women. After adjustment for sociodemographic, medical, and prenatal care characteristics, the greatest risks for delivering a LBW infant for Haitian women were chronic hypertension (OR = 6.8; 95% CI, 4.3, 10.6) and preeclampsia (OR = 3.2; 95% CI, 2.0, 5.1). For African-American women, the greatest risks for LBW infants were a history of delivering a LBW infant (OR = 3.9; 95% CI, 2.8, 5.4) and chronic hypertension (OR = 2.9; 95% CI, 2.1, 4.0). In a combined logistic regression model including interaction terms, chronic hypertension and preeclampsia continued to be associated with the greatest risk of LBW among all women. Conclusions: Differences in maternal risk factors and rates of LBW (8.2% vs. 10%) exist between Haitian and African-American women delivering infants in Massachusetts. While chronic hypertension and preeclampsia are strong risk factors for LBW for both Haitian and African-American women, unknown factors make these disorders much more potent for Haitian women.

Societal correlates of diabetes prevalence: An analysis across 94 countries

AIMS To quantify relationships between societal-level factors and diabetes prevalence and identify potential policy responses. METHODS Using data from International Diabetes Federation, World Health Organization, World Bank, and Food and Agricultural Organization, we extracted recent estimates for country-level variables: total caloric availability; sugar, animal fat, fruit and vegetable availability; physical inactivity markers (vehicles per capita and value-added from service sector); gross domestic product per capita (GDP); imports; and age-adjusted mortality rate. We used generalized linear models to investigate relationships between these factors and diabetes prevalence. RESULTS Median global diabetes prevalence was 6.4% in 2010. Every additional percentage point of calories from sugar/sweeteners and from animal fats were associated with 5% (OR: 1.05, 95% CI 1.02-1.07) and 3% (OR: 1.03, 95% CI 0.99-1.06) higher diabetes prevalence, respectively, while each additional unit in fruit and vegetable availability was associated with 3% lower diabetes prevalence (OR: 0.97, 95% CI 0.93-0.99). One percent higher GDP from the service industry was associated with a 1% higher diabetes prevalence (OR: 1.01, 95% CI 0.99-1.02). CONCLUSION Macro-level societal factors are associated with diabetes prevalence. Investigating how these factors affect individual-level diabetes risk may offer further insight into policy-level interventions.

Gender as risk factor for 30 days post-discharge hospital utilisation: a secondary data analysis

Objective In the 30 days after hospital discharge, hospital utilisation is common and costly. This study evaluated the association between gender and hospital utilisation within 30 days of discharge. Design Secondary data analysis using Poisson regression stratified by gender. Participants 737 English-speaking hospitalised adults from general medical service in urban, academic safety-net medical centre who participated in the Project Re-Engineered clinical trial (clinicaltrials.gov identifier: NCT00252057). Main outcome measure The primary end point was hospital utilisation, defined as total emergency department visits and hospital readmissions within 30 days after index discharge. Results Female subjects had a rate of 29 events for every 100 people and male subjects had a rate of 47 events for every 100 people (incident rate ratio (IRR) 1.62, 95% CI 1.28 to 2.06). Among men, risk factors included hospital utilisation in the 6 months prior to the index hospitalisation (IRR 3.55, 95% CI 2.38 to 5.29), being unmarried (IRR 1.72, 95% CI 1.12 to 2.64), having a positive depression screen (IRR 1.53, 95% CI 1.09 to 2.13) and no primary care physician (PCP) visit within 30 days (IRR 1.64, 95% CI 1.08 to 2.50). Among women, the only risk factor was hospital utilisation in the 6 months prior to the index hospitalisation (IRR 3.08, 95% CI 1.86 to 5.10). Conclusions In our data, male subjects had a higher rate of hospital utilisation within 30 days of discharge than female subjects. For men—but not for women—risk factors were being retired, unmarried, having depressive symptoms and having no PCP visit within 30 days. Interventions addressing these factors might lower hospital utilisation rates observed among men.

Glial cell line-derived neurotrophic factor enhances human islet posttransplantation survival.

Background. Development of pretransplantation islet culture strategies that preserve or enhance &bgr;-cell viability would eliminate the requirement for the large numbers of islets needed to restore insulin independence in type 1 diabetes patients. We investigated whether glial cell line–derived neurotrophic factor (GDNF) could improve human islet survival and posttransplantation function in diabetic mice. Methods. Human islets were cultured in medium supplemented with or without GDNF (100 ng/mL) and in vitro islet survival and function assessed by analyzing &bgr;-cell apoptosis and glucose stimulated insulin release. In vivo effects of GDNF were assessed in streptozotocin-induced diabetic nude mice transplanted under the kidney capsule with 2000 islet equivalents of human islets precultured in medium supplemented with or without GDNF. Results. In vitro, human islets cultured for 2 to 10 days in medium supplemented with GDNF showed lower &bgr;-cell death, increased Akt phosphorylation, and higher glucose-induced insulin secretion than islets cultured in vehicle. Human islets precultured in medium supplemented with GDNF restored more diabetic mice to normoglycemia and for a longer period after transplantation than islets cultured in vehicle. Conclusions. Our study shows that GDNF has beneficial effects on human islet survival and could be used to improve islet posttransplantation survival.

Association of high dietary saturated fat intake and uncontrolled diabetes with constipation: evidence from the National Health and Nutrition Examination Survey

Constipation is highly prevalent in the United States. The association of dietary fat intake with constipation has not been well studied. We recently reported that mice fed a high‐fat diet had higher incidence of constipation than regular diet fed mice. The aim of this study was to assess if increased intake of dietary saturated fat in humans is also associated with higher risk of constipation and reduced stool frequency.

A cost-minimizing diagnostic methodology for discrimination between neoplastic and non-neoplastic brain lesions

RATIONAL AND OBJECTIVES The purpose of this study was to make an improvement in the performance of a logistic regression model in predicting the presence of brain neoplasia with magnetic resonance spectroscopy data by using a new approach for logistic regression coefficient estimation. This new approach, termed cost minimizing (C-min), introduced by one of the authors (Chetty), uses the cost function for prediction outcomes to estimate model coefficients and the prediction decision rule. To do this requires use of a genetic algorithm. MATERIALS AND METHODS Consecutive patients with suspected brain neoplasms or recurrent neoplasia referred for magnetic resonance spectroscopy were enrolled once a final diagnosis was established by histopathology or clinical course, laboratory data, and serial imaging. For the same magnetic resonance spectroscopy explanatory (input) variables, logistic regression models were constructed with conventional and C-min coefficient estimates, and sensitivity and specificity outcomes were compared at alternative probability threshold levels. RESULTS The C-min approach dominated the conventional approach in 14 of 18 trials, in that C-min had either fewer of both false negatives and false positives, or it had the same number of one type, and less of the other type of diagnostic error. C-min was always less costly. CONCLUSION The C-min approach to logistic or other regression model estimation may be a step forward in reducing the cost and, often, the errors of diagnostic (and treatment) processes. However, this new approach must be validated on larger and more varied datasets, and its statistical performance characteristics determined before it can be implemented as a practical clinical tool.